HX00039160 


Columbia  (Bnttergftp 

intiieCttptrfltegork 

College  of  ^{jpgtctang  ano  Hmrgeons 
Hibvaxp 


A  TEXT-BOOK    OF  GYNAECOLOGICAL 
SURGERY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofgynaecOOberk 


Plate  I.  — Principal  Structures  of  the  Female  Pelvis,  seen  from  below 
(semi-diagrammatic) . 

i,  Vagina.  2,  Anus.  3,  External  sphincter.  4,  Tuber  ischii.  5,  Levator  ani  muscle.  6,  Coccyx. 
7,  Urethra.  8,  Bladder.  9,  Ureter.  10.  Anterior  fornix.  11,  Vaginal  cervix.  12,  Uterine  aitery. 
13,  Rectum.    14,  Trunk  of  uterine  and  superior  vesical  arteries.    15,  Pouch  of  Douglas.    16,  Sigmoid. 


A   TEXT-BOOK    OF 

GYNAECOLOGICAL 
SURGERY 


BY 

COMYNS    BERKELEY 

M.A.,  M.D.,  B.C.Cantab.,  F.R.C.P.Lond.,    M.R.C.S.Eng. 

Gynaecologist  and  Obstetrician  to  the  Middlesex  Hospital,  Senior 
Physician  to  the  City  of  London  Lying-in  Hospital,  Surgeon 
to  In-patients  at  the  Chelsea  Hospital  for  Women,  Consulting 
Gynaecologist  to  the  Eltham  Hospital,  Examiner  in  Diseases  of 
Women  and  Midwifery  to  the  University  of  Oxford  and  to  the 
Conjoint  Board  of  England ;  formerly  Examiner  in  Diseases  of 
Women   and  Midwifery  at  Apothecaries'  Hall,  London 

AND 

VICTOR    BONNEY 

M.S.,    M.D.,    B.SC.LOND.,    F.R.C.S.ENG.,    M.R.C.P.LOND. 

Assistant  Gynaecologist  and  Assistant  Obstetrician  to  the  Middlesex 
Hospital,  Senior  Surgeon  to  Out-patients  at  the  Chelsea  Hospital  for 
Women,  Gynaecologist  to  the  Hospital  for  Epilepsy  and  Nervous 
Diseases,  Maida  Vale  ;  formerly  Hunterian  Professor,  Royal  College 
of  Surgeons  of  England,  and  Emden  Research  Scholar,  Cancer 
Investigation  Laboratories,  Middlesex  Hospital 


WITH    392    FIGURES    IN    THE    TEXT    FROM    DRAWINGS 
BY  VICTOR  BONNEY,  AND   16   COLOURED   PLATES 


NEW  YORK 

FUNK  AND  WAGNALLS  COMPANY 

1911 


AIX    RIGHTS    RESERVED 


3 


en 


ID 


TO 

WILLIAM    DUNCAN    AND    JOHN    BLAND-SUTTON 

OUR    SPONSORS    IN    THIS   BRANCH    OF    SURGERY 


PREFACE 

This  book,  which  is  concerned  wholly  with  the  operative 
side  of  gynaecology,  is  a  record  of  our  own  personal  methods, 
and  of  experience  acquired  during  our  years  of  service 
at  the  Middlesex  Hospital  and  the  Chelsea  Hospital  for 
Women.  It  may  also  be  taken  as  reflecting  the  practice 
of  the  school  of  gynaecological  surgery  to  which  we  belong. 
It  sets  forth  in  detail  the  indications  for  gynaecological 
operations,  the  preoperative  preparation,  the  operative 
technique,  the  postoperative  treatment,  and  the  dangers 
to  be  avoided,  with  the  possible  complications  and  their 
appropriate  treatment.  The  black-and-white  illustrations, 
depicting  the  successive  stages  of  all  the  most  important 
and  the  most  frequently  performed  operations,  will,  we 
believe,  be  found  helpful  in  elucidating  the  text.  The 
subjects  of  the  coloured  plates  have  been  carefully  chosen 
with  the  object  of  illustrating  the  female  pelvic  organs  in 
their  normal  and  in  various  pathological  states. 

We  venture  to  hope  that  the  volume  will  be  of  service 
on  the  one  hand  to  those  who  are  proposing  to  follow  this 
department  of  surgery  more  particularly,  and  on  the  other 
hand  to  those  who  are  occasionally  called  upon  to  perform 
gynaecological  operations,  and  have  not  had  opportunity 
for  acquiring  the  ripe  experience  which  long  apprenticeship 
in  the  gynaecological  wards  and  operating  theatre  brings. 

To  our  publishers  we  must  express  our  thanks  for  the 
courtesy  with  which  they  have  carried  out  our  wishes 
and  the  care  with  which  the  work  has  been  produced. 

January,    191 1 


CONTENTS 


CHAPTER  PAGE 

i.  General  Operative  Considerations  i 


2.  Surgical  Technique       ..... 

3.  Operating  Theatre  and  Appointments 

4.  Operations  in  Private  Houses 

5.  Examination  and  Preparation  of  the  Patient 

6.  Operations  on  the  Vulva     .... 

7.  Operations  on  the  Vagina    .... 

8.  Operations  on  the  Cervix     .... 

9.  Operations  on  the  Cavity  of  the  Uterus    . 

10.  Hysterectomy  :    General  Considerations 

11.  Vaginal  Hysterectomy  .... 

12.  Radical    Hystero-Vaginectomy    by    Paravaginal 

Section       ....... 

13.  Opening  and  Closing  the  Abdominal  Cavity 

14.  Subtotal    Hysterectomy   by  the  Routine    Clamp 

and  Ligature  Methods      .... 

15.  Abdominal  Total  Hysterectomy  . 

16.  Hysterectomy  for  Cervical  Myoma 

17.  The  Radical  Abdominal  Operation  for  Carcinoma 

of  the  Cervix   ...... 

18.  Operations  for  Broad-Ligament  Myomata    . 

19.  Abdominal  Myomectomy         .... 

20.  Cesarean  Section  ..... 

21.  utriculo plasty      ...... 

22.  Operations  to  Remedy  Malpositions  of  the  Uterl 

23.  Ovariotomy    ....... 

24.  Operations  on  the  Broad  Ligament 


7 
5i 
65 
7i 
$7 
127 

153 

185 
212 
227 

261 

276 

292 

319 
338 

361 
406 

413 

421 

434 
438 
452 
463 


x  CONTENTS 

CHAPTER  PAGE 

25.  Operations  on  the  Fallopian  Tubes  and  Ovaries  476 

26.  Operations  for  Extra-Uterine  Gestation     .         .  503 

27.  Ovarian  Tumours  Complicating  Pregnancy,  Labour 

and  the  puerperium          .....  512 

28.  Uterine  Myomata  Complicating  Pregnancy,  Labour 

and  the  puerperium          .....  516 

29.  Cancer  of  the  Cervix  Uteri  Complicating  Preg- 

nancy and  Labour    ......  521 

30.  Operations  on  the  Intestinal  Canal    .         .         .  524 

31.  Operation-Wounds  of  the  Bladder,  Ureter,  and 

Bowel        ........  539 

32.  Postoperative  Treatment      .....  547 

33.  Methods  of  Administering  Saline  Solution          .  573 

34.  Postoperative  Complications         ....  582 

35.  Postoperative  Complications  (continued)         .         .  598 

36.  Postoperative  Complications  (continued)         .         .  616 

37.  Postoperative  Complications  (continued)         .         .  629 

38.  Postoperative  Complications  (continued)         .         .  650 

39.  Postoperative  Complications  (concluded)         .         .  665 

40.  Immediate  Results  of  Operations  on  the  Female 

Genital  Organs          ......  677 

41.  Remote   Results   of   Operations   on   the   Female 

Genital  Organs 695 

Index    .........  711 


LIST    OF    PLATES 

PLATE 

i.  Principal  Structures  of  the  Female  Pelvis,  seen 

from  below         .....  Frontispiece 

Facing  page 

2.  The  Female  Pelvic  Organs,  seen  from  above      .  276 

3.  Multiple  Myomata  of  the  Uterine  Body     .         .  292 

4.  Central  Cervical  Myoma 338 

5.  Myoma  of  the  Anterior  Uterine  Wall  and  Cervix  352 

6.  Myoma  of  the  Right  Broad  Ligament           .         .  406 

7.  multilocular    ovarian    adeno-cystoma    of    the 

Left  Side  ........  452 

8.  Ovarian  Dermoid  Cyst           .....  456 

9.  Bilateral  Papilliferous  Ovarian  Cysts        .         .  460 

10.  Bilateral  Malignant  Ovarian  Tumour          .         .  464 

11.  Broad-Ligament  Cyst  of  the  Left  Side        .         .  468 

12.  Bilateral  Hydro-Salpinx      .         .         .         .         .  478 

13.  Bilateral  Pyo-Salpinx           .....  484 

14.  Right  Tubo-Ovarian  Cyst      .....  494 

15.  Large  Ovarian  Abscess  of  the  Left  Side    .         .  496 

16.  Ruptured  Tubal  Pregnancy          ....  504 


A    TEXT-BOOK    OF 
GYNAECOLOGICAL  SURGERY 

CHAPTER    I 

GENERAL    OPERATIVE    CONSIDERATIONS 

Under  this  head  we  discuss  the  proper  bearing  of  the 
surgeon,  the  question  of  speed  in  operating,  and  the 
desirability  of  reducing  to  a  minimum  the  number  of 
operative  manipulations. 

THE  BEARING  OF  THE  SURGEON 

The  surgeon  when  operating  should  always  remember 
that  the  character  of  the  work  of  his  subordinates  will 
be  largely  influenced  by  his  own  bearing.  Whilst  it  is 
impossible  to  lay  down  definite  rules  suitable  for  all 
temperaments,  nevertheless  there  are  certain  points  a 
consideration  of  which  will,  we  trust,  prove  as  useful  to 
those  beginning  gynaecological  practice  as  they  have  been 
to  us. 

Anyone  who  has  taken  the  trouble  to  study  the  work 
of  a  number  of  operators  cannot  fail  to  have  observed 
how  variously  the  stress  and  strain  of  operation  is  borne 
by  different  minds,  and  will  deduce  from  a  consideration 
of  the  strong  and  weak  points  of  each  operator  some  con- 
ception of  the  ideal. 

The  keystone  of  the  surgeon's  bearing  should  be  self- 
control,  and  whilst  it  is  his  duty  to  keep  a  general  eye 


2  GYNECOLOGICAL  SURGERY 

upon  all  that  takes  place  in  the  operating  theatre,  and 
without  hesitation  to  correct  mistakes,  he  should  be  con- 
tinually on  his  guard  against  becoming  excited  or  losing 
his  temper.  The  man  who,  when  confronted  with  a  diffi- 
culty, gets  flurried  and  unsteady  has  mistaken  his  vocation, 
however  dexterous  he  may  be,  or  however  learned  in  the 
technical  details  of  his  art.  The  habit  of  abusing  assistants, 
the  instruments,  or  the  anaesthetist,  so  easily  acquired  and 
with  difficulty  lost,  is  not  one  to  be  commended ;  the 
mental  incertitude  of  which  such  behaviour  is  the  indirect 
expression  will  inevitably  spread  to  the  other  members  of 
the  staff,  so  that  at  the  very  time  when  the  surgeon  is 
most  in  need  of  effective  help  he  will  find  it  fail  him. 

The  assistants  should  be  encouraged  to  look  forward 
to  each  operating  day  as  one  of  strenuous  but  pleasurable 
work,  but  this  object  will  not  be  attained  if  constant  fault- 
finding forms  part  of  the  routine.  It  will  also  be  well 
for  the  surgeon  to  remember  that  his  bearing  will  be  the 
subject  of  keen  criticism  by  the  spectators,  and  that  there 
is  nothing  so  much  admired  as  fortitude  in  adversity.  On 
the  other  hand,  he  must  avoid  any  temptation  of  "  play- 
ing to  the  gallery,"  for  sooner  or  later  such  conduct  will 
be  detrimental  to  the  patient.  A  surgeon  should  not 
gossip,  for  it  is  impossible  for  him  to  do  his  best  work 
if  he  is  continually  engaged  in  irrelevant  chatter  ;  whilst 
a  silent  surgeon  is  unprofitable  to  those  around  him,  for 
he  should  clearly  outline  the  steps  of  the  operation  as  it 
proceeds,  and  by  apposite  and  instructive  remarks  compel 
the  attention  of  those  who  are  there  to  learn.  It  is  the 
mark  of  a  good  operator  to  become  more  and  more  silent 
as  the  difficulty  of  the  operation  increases,  of  a  bad  one 
to  become  more  loquacious. 

It  falls  to  the  lot  of  every  surgeon,  sooner  or  later,  to 
stand  face  to  face  with  threatened  disaster  when  operating, 
and  even  among  the  best  there  must  be  moments  when 
the  heart  sinks.  On  such  occasions  the  operator  should 
remember  that  if  he  does  not  hesitate,  the  deliberate  and 


GENERAL  OPERATIVE  CONSIDERATIONS    3 

vigorous  application  of  general  surgical  principles  will 
always,  temporarily  at  any  rate,  surmount  the  difficulty, 
whilst  half-hearted,  and  nervous  measures  merely  increase 
it.  A  sturdy  belief  in  his  own  powers  and  a  refusal  to 
accept  defeat  are  the  best  assets  of  a  calling  which  pre- 
eminently demands  moral  courage. 

Before  operating,  the  surgeon  should  go  over  in  his 
mind  the  various  possibilities  of  the  projected  procedure, 
so  that  he  may  be  the  better  able  to  meet  them.  Like- 
wise, after  the  operation  he  will  find  it  profitable  to  recall 
the  difficulties  he  has  encountered  and  the  technique  he 
adopted  in  surmounting  them,  for  it  is  only  by  cultivat- 
ing a  habit  of  self-examination  that  his  workmanship  will 
continue  to  improve. 

In  hospitals  it  necessarily  happens  that  a  very  large 
amount  of  work  must  be  got  through  in  a  single  operating 
day,  but  it  is  a  grave  mistake,  for  mere  show,  to  undertake 
more  work  of  an  arduous  nature  than  the  physique  and 
mind  of  all  concerned  can  fairly  tolerate.  Operations 
performed  when  everybody  is  tired  out  are  ill  done  ;  the 
surgeon's  hand  and  mind  become  less  steady,  his  assistants 
are  less  apt,  the  nurses  are  less  careful,  and  the  patient 
is  exhausted  by  long  waiting. 

The  surgeon  would  do  well  to  recollect  that  until  the 
day  of  his  retirement  he  should  take  -  every  opportunity 
to  improve  his  technique,  for  he  may  rest  assured  that 
he  will  never  be  perfect,  and  that  there  is  some  good 
lesson  to  be  learnt  from  seeing  the  work  of  any  operator, 
even  if  it  be  only  what  to  avoid. 

Lastly,  nothing  is  so  contemptible  as  publicly  to  decry 
the  work  of  other  men.  To  hear  a  surgeon  loudly  pro- 
claiming the  faults  and  failures  of  another  indicates  that 
he  has  not  attained  to  that  experience  which  begets  leniency, 
shows  a  lack  of  good-fellowship,  and  argues  an  absence 
of  nicer  feeling  which  sooner  or  later  will  be  injurious  to 
his  patients,  and  which  makes  a  man  an  unpleasant  and 
unprofitable  member  of  society. 


4  GYNAECOLOGICAL    SURGERY 

SPEED   IN   OPERATING 

Speed  as  an  indication  of  perfect  operative  technique 
is  the  characteristic  of  a  fine  surgeon,  as  a  striving  after 
effect  is  the  stock-in-trade  of  the  charlatan.  An  operation 
rapidly  yet  correctly  performed  has  many  advantages 
over  one  as  technically  correct  yet  laboriously  and  tediously 
accomplished.  The  period  over  which  haemorrhage  may 
occur  is  shortened,  the  tissues  are  less  bruised,  the  time 
of  exposure  of  the  peritoneum  in  abdominal  section  is 
minimized,  the  dose  of  the  anaesthetic  with  its  attendant 
evils  is  reduced,  and  shock,  which  is  the  expression  of  all 
these  factors,  is  lessened.  Moreover,  less  strain  is  thrown 
upon  the  temper  and  the  legs  of  the  operator  and  his  assist- 
ants, and  the  interest  of  the  latter  and  of  the  onlookers  is 
maintained  at  its  highest  level.  There  is,  however,  one 
aspect  of  rapid  operating  which  must  not  be  lost  sight  of, 
namely,  the  fact  that  there  is  a  much  greater  liability  for 
oozing  to  occur  after  the  operation  has  terminated  ;  for 
where  a  man  has  taken  two  hours  to  perform  an  operation, 
any  bleeding,  if  it  is  going  to  occur,  will  have  declared  itself 
in  that  time ;  whereas,  had  the  wound  been  finally  closed 
at  the  end  of  a  quarter  of  an  hour,  the  opportunity  of  dis- 
covering the  bleeding  would  have  been  lost.  It  is  for  this 
reason  that  the  results  of  the  brilliant  surgical  prodigy 
and  of  the  old-fashioned  laborious  plodder  are  not 
so  different  as  at  first  sight  might  be  expected,  since 
the  after-results  due  to  mauling  and  exposure  of  the 
tissues  by  the  latter  are  in  the  former  balanced  by  the 
local  peritonitis  and  fever  set  up  by  post-operative 
oozing. 

Rapid  operating,  then,  should  be  acquired  only  as  the 
result  of  continual  practice  and  constant  thought  as  to 
how  best  to  reduce  the  manipulations  required  without 
sacrificing  the  efficiency  of  the  operation  or  increasing  the 
danger  to  the  patient.  Thus  obtained,  speed  is  an  attribute 
in  the  highest  degree  to  be  desired  and  striven  for. 


GENERAL  OPERATIVE  CONSIDERATIONS    5 

It  is  impossible  to  lay  down  any  rules  as  to  speed  for 
the  various  operations  dealt  with  in  this  work,  so  much  de- 
pending upon  the  nature  of  the  case  and  the  circumstances 
in  which  they  are  performed,  for  an  operation  which  may 
only  take  thirty  minutes  with  full  hospital  assistance, 
may  take  double  that  time  when  performed  with  a  single 
assistant  in  a  private  house. 

We  find  that  all  major  operations,  with  a  very  few 
exceptions,  such  as  the  radical  extirpation  for  carcinoma 
of  the  cervix,  can  be  performed  well  under  an  hour,  and 
most  minor  operations  under  half  an  hour. 

Patients  undergoing  even  the  severest  operations  will 
maintain  their  condition  well  for  an  hour,  but  every  five 
minutes  after  that  period  is  increasingly  detrimental  to 
their  welfare. 

OPERATIVE   MANIPULATION 

The  surgeon  should  continually  endeavour  to  reduce  the 
number  of  manipulations  required  in  a  given  procedure  to 
the  minimum  consistent  with  its  proper  performance.  Any- 
one who  will  take  the  trouble  attentively  to  observe  the 
performance  of  an  operation  cannot  fail  to  be  struck  by 
the  number  of  unnecessary  movements  made.  This  wastage 
of  time  and  effort  cannot,  of  course,  be  entirely  abrogated, 
much  of  it  being  the  expression  of  the  wavering  intentions 
of  the  operator  in  the  face  of  new  difficulties  continually 
presenting  themselves.  Nevertheless  some  part  of  it  is  due 
solely  to  bad  habits  and  a  lack  of  determination  on  the  part 
of  the  surgeon  to  subject  his  movements  to  examination, 
and  to  improve  upon  them  wherever  possible.  Thus,  to  per- 
form the  primary  incision  through  the  abdominal  skin  and 
fascia  by  a  series  of  niggling  cuts  is  an  example  of  bad 
technique,  as  is  the  practice  of  passing  a  needle  on  a  forceps, 
removing  and  laying  down  the  forceps,  and  then  extracting 
the  needle  with  the  fingers  of  the  left  hand.  The  needle 
should,  of  course,  be  extracted  with  the  forceps  and  the 
two  returned  to  the  instrument-tray  together. 


6  GYNECOLOGICAL  SURGERY 

These  examples  might  be  multiplied  many  times,  but  they 
will  suffice  for  the  purpose  we  have  in  view.  Manipulations 
should  be  conducted  with  the  finger-tips  ;  there  is  nothing 
so  inelegant  as  to  see  the  surgeon's  hands  sprawling  over 
the  operation  area,  obstructing  not  only  the  spectators' 
but  his  own  view.  It  is  better,  whenever  possible,  to  keep 
the  hands  out  of  the  wound  entirely  by  performing  the 
necessary  manoeuvres  instrumentally.  The  long  dissecting- 
forceps  illustrated  on  p.  9  will  be  found  very  useful  in 
this  connexion. 


CHAPTER   II 
SURGICAL    TECHNIQUE 

INSTRUMENTS 

The  aim  of  the  surgeon  should  be  to  use  as  few  instru- 
ments as  is  compatible  with  the  efficient  performance  of  the 
operation  he  is  engaged  upon.  There  are  many  reasons  for 
this.  The  fewer  instruments  a  surgeon  has,  the  more  uses 
he  learns  to  put  them  to,  and  he  is  thus  able  to  save  time 
in  immaterial  details  of  the  operation  which  can  be  profit- 
ably expended  on  its  essential  features.  Thus,  a  Spencer 
Wells  pressure-forceps  may  be  efficiently  used  for  hcemo- 
stasis,  as  a  retractor,  as  a  needle-holder,  as  a  dissecting 
forceps,  as  a  probe,  and  as  a  swab-holder.  The  surgeon 
who  is  accustomed  to  make  one  instrument  serve  many 
purposes  maintains  his  self-reliance,  no  matter  what  the 
nature  of  the  operation  or  the  circumstances  under  which 
he  is  called  upon  to  perform  it,  whilst  one  whose  habit  it  is 
to  use  a  special  instrument  for  every  separate  manoeuvre 
may  become  flurried,  unstable,  and  unreliable  when  these 
are  not  forthcoming. 

In  choosing  his  instruments,  a  surgeon  should  therefore 
have  these  points  in  mind  and  avoid  if  possible  those 
whose  uses  are  limited  to  some  special  manoeuvre,  and 
should  remember  that  a  fictitious  value  has  often  been 
and  will  again  be  given  to  some  instrument  solely  on 
account  of  the  halo  surrounding  its  inventor's  name.  It 
has  been  our  experience,  that  those  who  are  for  ever 
advocating  the  advantages  of  some  new  instrument  lack 
the  manipulative  skill  and  ready  resource  which  are  the 
characteristics  of  the  surgeon  by  grace  of  nature.  Com- 
plicated instruments  should  be  avoided  whenever  possible, 

7 


8  GYNECOLOGICAL  SURGERY 

for,  however  well  they  may  work  in  the  instrument  maker's 
shop,  they  soon  get  out  of  order  from  the  wear  and  tear 
of  boiling.  In  the  long  run  it  is  cheapest  to  use  instru- 
ments of  the  best  steel  and  of  the  finest  workmanship, 
for  though  their  initial  cost  be  greater,  they  last  longer 
and  are  not  likely  to  fail  at  some  critical  moment.  Instru- 
ments, we  would  add,  should  be  kept  in  perfect  order, 
for  such  defects  as  sprung  forceps,  loose-jointed  scissors, 
and  blunt  knives,  though  not  very  noticeable  in  a  straight- 
forward operation,  become  painfully  apparent  when  the 
difficulty  and  strain  of  the  case  test  every  joint  of  the 
surgeon's  armour.  Simplicity,  then,  in  instruments,  as  in 
other  things,  should  be  the  key-note  of  the  operation, 
but  simplicity  with  efficiency.  In  medio  tutissimus  ibis  : 
an  outfit  so  large  as  to  require  for  its  conveyance  a  bag 
resembling  a  seaman's  chest  is  ridiculous  ;  one  so  small 
that  it  can  be  carried  in  the  trousers  pocket  is  dangerous. 
The  following  are  the  instruments  we  use  : 
Scalpel  and  scalpel  carrier. — The  scalpel  measures 
5f  in.,  its  blade  being  if  in.  Larger  instruments  than 
these  are  inconvenient  for  use  in  the  pelvis.  Scalpels 
should  not  be  boiled,   at  all  events  for  more  than  a  few 


Scale  f 


Fig.  1. — Berkeley's  scalpel  case. 

minutes,  or  the  edge  will  be  blunted  ;  they  are  best  ste- 
rilized by  absolute  alcohol,  and  the  scalpel  case  shown  in 
Fig.  i,  which  keeps  them  continuously  immersed  in  this 
fluid,  is  a  most  convenient  carrier. 

Forceps.  Dissecting.  —  Dissecting  forceps  should  be 
7  in.  long  for  use  in  the  bottom  of  the  pelvis  ;  the  whole 
of  the  last  inch  of  the  jaws  should  approximate  and  be 


INSTRUMENTS  9 

grooved  transversely,  for  the  convenient  seizing  of  needles 
and  masses  of  tissue,  and  their  points  should  be  rat-toothed 


Fig.  2. — Bonney's  dissecting  forceps. 

to  give  a  better  hold  in  manoeuvres  requiring  delicate 
manipulation.  The  instrument  shown  in  Fig.  2  fulfils 
these  requirements. 

Spencer  Wells. — Two   sizes    are    required,    5   in.    and 
7  in.      The  jaws   should    approximate   before   the   ratchet 


Fig.   3. — Long  Spencer  Wells  forceps. 


Fig.  3a. — Short  Spencer  Wells  forceps. 

locks,  so  that  it  is  possible  to  seize  small  objects  without 
clamping  them  (Figs.  3  and  3a). 

Kocher's. — These  forceps  are  of  a  similar  shape  to 
the  Spencer  Wells,  but  their  jaws  are  longer  (2  in.)  and 
their  ends  are  furnished  with  rat-teeth.  They  are  par- 
ticularly  convenient   for  holding  masses   of  tissue   firmly, 


10 


GYNAECOLOGICAL  SURGERY 


as,   for  instance,   when  clamping   the  uterine   arteries   on 
the  side  of  the  uterus.    We  use  two  sizes,  5|  in.  with  straight 


Fig.  4a. — Angular  Kocher's  forceps 


jaws,  and  8  in.  with  angular  jaws,  the  latter  being  very 
useful  for  panhysterectomy  and  Wertheim's  operation 
(Figs.  4  and  4a). 

Ring  forceps. — These  should  be  10  in.  long  (Fig.  5). 
They  are  perhaps  the  most  generally  useful  forceps  in  the 
whole  outfit,  for  besides  carrying  swabs  they  are  admir- 


Fig.  5. — Ring  forceps. 


able  for  securing  and  tying  bleeding-points  deep  down  in 
the  pelvis,  and  for  steadying  and  pulling  up  diseased 
appendages,  whilst  they  make  very  good  bowel  clamps. 


INSTRUMENTS 


ii 


Round-ligament  forceps. — The  forceps  shown  in  Fig.  $a 
are  required  for  the  operation  of  intraperitoneal  shortening 
of  the  round  ligaments. 


Fig.  5a. — Round-ligament  forceps 


Shot  forceps. — For  closure  of   the  shot-and-coil   suture 
a  short  pair  of  forceps  similar  to 
those  used    by  a  carpenter  will 
suffice  (Figs.  6  and  6a). 

Scissors. — -For  gynaecological 
surgery  the  scissors  should  be 
6  in.    and    7   in.    long.     Of   the 


iifflniiii— 


Fig.  6. — Shot-and-coil 
ligature. 


Fig.  6a. — Compression  forceps  for  shot-and-coil  ligature. 

former  size  three  types  are  required,  those  with  straight 
blunt-pointed  blades,  those  with  blunt-pointed  blades  bent 
on  the  flat,  and  those  with  sharp-pointed  blades  set  at 
an  angle  in  the  plane  of  the  shanks.  The  longer  scissors 
are  most  useful  for  deep  abdominal  work,  and  the  best 
pattern  is  Mayo's,  which  has  straight,  blunt-pointed 
blades.  We  have  had  a  pair  made  to  the  same  pattern 
with  blunt-pointed  blades  bent  on  the  flat,  which  we  have 
found  of  great  service,  especially  in  the  radical  operation 
for   carcinoma  of  the   cervix  (Fig.  7). 

Yolsella. — The    best-pattern    volsella    is    Fenton's.      It 
is  7  in.  long,  and  effects  a  very  firm  hold  (Fig.  8). 


12 


GYNECOLOGICAL  SURGERY 


Retractors.    Abdominal. — We  have  tried  various  patterns 
on  the  market,  and   find   the   two   best   to  be  the  gloved 


Fig.  7. — Scissors  of  various  types. 

a,  blunt-pointed  blades  bent  on  the  flat;   b,  straight  blunt-pointed  Mayo's  scissors; 
c,  angular-pointed  scissors. 

hand   and   a  self-retaining    form    designed    by   one   of  us 
(Fig.   9).      This  instrument    consists   of  two  parallel  bars 


Fig.  8. — Fenton's  bull-dog  volsella. 


with  a  solid  retracting  blade  on  each,  and  two  removable 
solid  blades  which  slide  on  the  bars  and  are  automatically 
fixed  at  any  point  directly  pressure  is  applied.     One  cross- 


INSTRUMENTS 


13 


bar  with  a  ratchet  which  controls  the  parallel  bars  is  also 
fitted.  A  ratchet  catch  is  fixed  to  the  sliding  parallel 
bar,  which  works  in  conjunction  with  the  ratchet  on  the 
cross-bar,  thus  enabling  the  operator  to  fix  the  blades 
at  any  point,  without  danger  of  slipping.  By  means  of 
the  sliding  blades  this  instrument  will  efficiently  retract 
the  largest  incisions,  so  that  additional  retractors  are 
unnecessary.  On  the  other  hand,  by  removing  these 
blades    the    instrument    can   be    used   for   small   incisions. 


Fig.  9. — Berkeley's  retractor. 


The  ratchet  effectually  controls  the  tendency  to  slipping 
noticed  with  Gosset's  retractor  when  the  muscles  are  rigid 
or  the  instrument  is  somewhat  worn,  and  the  four  blades 
also  prevent  the  instrument  from  slewing  round,  which 
is  a  common  fault  with  Gosset's  retractor.  Berkeley's 
retractor  is  particularly  useful  in  the  radical  operation 
for  carcinoma  of  the  cervix,  a  splendid  view  of  the  field 
of  operation  being  obtained  by  its  use,  and  its  four  blades 
keeping  the   india-rubber  sheeting  in  position. 

Vaginal. — Auvard's  weighted  speculum  (Fig.  10)  is  a 
necessity  for  the  proper  performance  of  vaginal  surgery. 
It  should  not  be  made  unnecessarily  heavy,   as  it  is  apt 


i4 


GYNECOLOGICAL  SURGERY 


in  that  case  to  tear  or  bruise  the  soft  parts.  The  operator 
must  remember  that  should  it  slip  out  of  the  vagina  it 
will  break  any  china  receptacle  that  may  be  underneath  it. 
In  minor  operations  on  virgins  the  use  of  Auvard's 
speculum  is  undesirable  or  impossible  without  lacerating 
the  vagina.  In  such  cases  we 
prefer  the  use  of  a  narrow  vaginal 
retractor  held  by  the  hand  (Fig. 
ii). 

For  vaginal  hysterectomy,  hys- 
tero-vaginectomy,  and  paravaginal 
section,  longer  and  broader  re- 
tractors are  convenient  for  holding 
back  the  bladder  or  rectum.  The 
pattern  we  use  has  a  blade  measur- 
ing 4  in.  by  2  in.   (Fig.  12). 

Clamps.  The  clip  retractor. — 
This  instrument  was  devised  for 
securing  india-rubber  sheeting  over 
the  edge  of  the  wound  and  abdo- 
minal skin  in  cases  where  infection 
or  bruising  of  the  wound-edge  is  to 
be  expected  from  the  nature  of  the 
operation.  It  also  forms  a  useful 
retractor  (Fig.  13). 

Vaginal  clamp.  —  We  devised 
the  instrument  shown  in  Fig.  14  to 
clamp  the  vagina  preparatory  to  its  section  in  Wer- 
theim's  operation,  after  having  tried  every  other  pattern 
made  for  the  same  purpose  we  could  obtain.  The  blades, 
which  are  set  at  a  T-angle  to  the  shank,  measure 
2\  in.  across  ;  they  are  longitudinally  serrated,  and  are 
slightly  bowed  so  as  to  close  with  a  spring  action.  The 
shanks  measure  6  in.  to  the  joint,  and  are  bowed  so  as 
to  include  the  uterus  without  compressing  it,  being  at 
their  widest  points  2|  in„  apart.  The  handles  measure 
7  in.  from  the  joint,  and  are  provided  with  two  pairs  of 


Fig.  10.— Auvard's 
speculum. 


INSTRUMENTS 


15 


Fig.   11. — Narrow  vaginal 
retractor. 


Fig.   12. — Broad  vaginal 
retractor. 


Fig.   13. — Bonney's  clip  retractor. 


Fig.  14. — The  Berkeley-Bonney  vaginal  clamp. 


i6 


GYNECOLOGICAL  SURGERY 


finger-rings,  the  lower  of  which  end  3|  in.  from  the  joint 
and  are  used  for  adjustment,  whilst  the  upper,  which  are 


Fig.   15. — Intestinal  clamp. 


at  the  extreme  ends  of  the  handles,  are  used  when  actually 
clamping  the  vagina. 

The  blades  of  these  forceps  will  be  found  amply  large 
enough  to  span  the  breadth  of  any  vagina,  their  failure 
to  accomplish  this  in  some  operators'  hands  being  due 
to  the  fact  that  the  previous  division  of  the  paravaginal 
tissue  has  not  been  sufficient.  This  clamp  secures  a  very 
firm  hold,  minimizes  the  risk  of  injuring  the  ureter,  and 
allows  of  direct  traction  upwards  on  the  vagina. 

Intestinal  clamps. — The  ring  forceps  already  described 
make  very  efficient  bowel  clamps  where  end-to-end  anasto- 
mosis has  to  be  performed.  For  lateral  anastomosis  they 
will  not   do.     We,   therefore,   always   carry  a  pair  of  the 


13  13 

Fig.  16. — Bonney's  needles — curved  and  half-circle. 

clamps  illustrated  in  Fig.  15,  their  blades  being  4!  in.  long. 
These  clamps  may  be  also  very  conveniently  used  in  place 
of  Playfair's  probe  in  minor  operations  on  the  uterus. 


INSTRUMENTS 


J7 


Needles.     Curved. — For   many    years    we    have    used 
curved  needles   of  the  pattern  shown  in  Fig.    16.     They 
have  the  great  advantage  of  being  able  to  be  firmly  held 
at  any  angle  in  any  forceps  ;    they  are  also  easy  to  thread 
and  difficult  to  blunt.     The  front  half  of  the  haft  of  the 
needle  is  bayonet-shaped       _____^=============»=> 

with  sharp-cutting  edges,  s!L  '/z 

whilst  the  hinder  half  is        Fig#  16«.— Long  straight  needle. 

flat  with  a  circular  eye. 

They  are  made  in  various  shapes  and  sizes,  from  No.   i, 

suitable  for  perineoplasty,    down   to   No.    13,   suitable   for 

intestinal  anastomosis. 

Straight. — For  suturing  the 
skin  wound,  4-in.  bayonet-ended 
needles  are  the  best  (Fig.  16a). 

Needles  should  be  carried 
in  the  small  perforated  metal 
box  in  which  they  have  been 
sterilized  (Fig.  17). 

Worrall's  needle. — We  never  use  needles  fixed  on 
handles,  for  they  are  clumsy  and  soon  get  blunt.  We  must, 
however,  except  an  aneurysm-needle,  which  we  use  to  raise 


Fig.  17. — Needle-box. 


Fig.   18. — Aneurysm-needle. 


Fig.   18a. — Worrall's  needle. 

the  ureter  in  Wertheim's  operation,  and  the  notched  needle 
designed  by  Worrall,  which  is  an  extremely  useful  instrument 
when  working  in  a  position  difficult  of  accessibility,  such 
as  the  depth  of  the  pelvis  in  Wertheim's  operation,  or  high 
up  in  the  vagina  in  vaginal  hysterectomy  (Figs.  18  and  18a). 
C 


i8 


GYNECOLOGICAL  SURGERY 


Michel's    clips. — We  have  referred  to    the    advantages 
of  these   (p.  288).     The  best  apparatus  for  applying  them 

is  that  shown  in 
Fig.  19,  in  which 
the  adaptation  for- 
ceps is  furnished 
with  a  bridge  on 
which  the  clips 
are    carried. 

Silk  box.— The 
most  convenient 
apparatus  for  car- 
rying silk  is  a 
metal  box  contain- 
ing three  reels,  so 
arranged  that  the 
threads,  Nos.  4,  2, 
1,  can  be  with- 
drawn without  ex- 
posing the  whole 
reel.  This  metal 
box  may  be  boiled 
with    the   silk   remaining   in   situ    (Fig.    20). 

Gloye  box. — If  rubber  gloves 
are  sterilized  with  the  instru- 


Fig.  19. — a,  Forceps  for  applying 
Michel's  clips ;  b,  forceps  for  re- 
moving  them. 


Fig.  21.— Glove  box. 

ments  they  are  very  likely  to 
Fig^O.-Silk-hgature  box.    be  perforated.     To  obviate  this, 

and  to  save  the  time  wasted 
by  two  separate  boilings,  we  use  a  perforated  metal  box  to 
contain  them  during  sterilization  and  transport  (Fig.  21). 


INSTRUMENTS 


19 


Infuser. — The    infusion    apparatus    shown    in    Fig.    22 
holds  a  container  for  the  solution,   india-rubber  tubing,   a 


Fig.  22, — Berkeley's  saline  infusion  apparatus. 

scalpel,  dissecting-forceps,  aneurysm-needle,  a  sewing-needle, 
and  cannula  in  a  small  compass,  measuring  8|  in.  by 
if  in.  It  should  reside  perpetually  in 
the  operator's  bag,  for  he  may  be  called 
upon  to  perform  this  operation  at  any 
moment. 

Sounds. — The  ordinary  uterine  sound 
should  be  made  of  steel,  except  its  last 
2|  in.,  which  should  be  of  copper,  so 
that  it  can  be  bent  if  necessary  (Fig.  23). 
For  sounding  the  bladder  the  smallest- 
sized  Fenton's  dilator  does  very  well  in 
the  absence  of  the  ordinary  bladder-sound 
(Fig.  24). 

Dilators. — Fenton's     dilators     will     be 
found  the  most  useful,  because   they  are   double-ended,  so 


Fig.  22a.~ 
Cannula  of 
Berkeley's 
saline  infuser. 


sc!4 


Fig.  23. — Uterine  sound. 


20 


GYNAECOLOGICAL  SURGERY 


that    the    number  of  instruments    required    to    be   carried 
for  this  purpose  is  halved  ;    they   can   be   boiled,  and  the 


r 


Fig.  24. — Bladder-sound. 


curve    on    the    instrument     facilitates    their    introduction. 
Owing  to  the  leverage  obtained  by  their  length,   they  are 


Fig.  25. — Fenton's   uterine  dilators. 

very  powerful  instruments,  and  must  be  used  with  caution 
(Fig.  25). 

Curette. — We   always   use  for  gynaecological  operations 
the  flushing  curette  shown  in  Fig.   26.     It  is  unnecessary 


Sc  •  ' 

Fig.  26. — Flushing  curette. 

for  the  blade  to  be  a  greater  breadth  than  f  in.,  and  this 
can  be  passed  into  the  uterus  easily  after  a  dilatation  to 
No.  9  Fenton. 

For  curetting  the  cervix,  our  practice  is  to  use  a  sharp 
scoop  (Fig.  27). 


Fig.  27. — Sharp  scoop. 


Clover's  crutch. — -In    hospital    practice    the    patient    is 
best  retained  in  the  lithotomy  position  by  poles  and  foot 


INSTRUMENTS 


21 


rests,   but   for   operations   in  private   houses   an   ordinary- 
Clover's  crutch  is  a  necessity  (Fig.  28). 

Paquelin's  cautery. — Paquelin's 
cautery  is  useful  to  burn  the  raw- 
base  left  after  the  removal  of  a 
urethral  caruncle.  It  is  also  used  to 
cauterize  the  cervix  in  malignant 
disease  after  curetting,  and  to  am- 
putate the  vagina  in  Wertheim's 
operation.  This  cautery,  as  usu- 
ally supplied  by  instrument  makers, 
is  an  expensive  instrument,  and 
that  sold  for  doing  "poker"  work 
will  serve  the  same  purpose,  and 
cost  about  a  tenth  of  the  price. 

To  make  these  cauteries  work  satisfactorily,  the  surgeon 
should  remember  that  old  naphtha  must  be  used. 

Table. — For  hospital  work  the  table  described  at  p.  52 
is,    we   find,   entirely   satisfactory    (Fig.   29).     For  private 


Fig.  28.— Glover's 
crutch. 


Fig.  29. — Hospital  operating  table. 


22  GYNECOLOGICAL  SURGERY 

work  it  is  the  greatest  advantage  to  the  surgeon  to  possess 
a  portable  table  of  his  own.  Many  nursing-homes,  it  is 
true,  are  well  provided  in  this  respect,  but  there  are  others 
in  which  the  apparatus  that  does  duty  for  it  is  incapable 
of  giving  an  efficient  Trendelenburg  tilt.  For  operations 
in  private  houses  an  efficient  table  must  be  either  possessed 
or  borrowed,  and,  in  the  latter  event,  emergency  and  want 


Fig.  30. — Berkeley's  portable  table. 

of  time  may  compel  the  surgeon  to  operate  on  an  improvised 
table,  greatly  to  the  patient's  disadvantage. 

The  portable  table  designed  by  one  of  us*  (Fig.  30), 
can  be  rapidly  packed  and  as  rapidly  put  together  ;  its 
weight  (34  lb.)  allows  of  its  being  easily  carried,  and  its 
mechanism,  simple  withal,  gives  a  correct  Trendelenburg 
tilt  to  any  required  angle.  It  has  been  tested  up  to  20 
stones  and  found  quite  rigid. 

*  It  is  manufactured  by  Messrs.  Allen  and  Hanburys. 


SUTURE   MATERIAL  23 

SUTURE    AND    LIGATURE    MATERIAL 

Sutures  and  ligatures  may  consist  of  silk,  thread,  silk- 
worm-gut, or  catgut.  The  relative  advantages  of  these 
materials  may  be  discussed  under  five  headings :  ease  of 
sterilization,  strength,  security,  absorbability,  cost. 

Ease  of  sterilization. — -The  only  material  that  runs 
any  risk  of  being  inefficiently  sterilized  is  catgut,  for  the 
other  three  substances  are  not  injured  by  boiling.  There 
are  various  processes  by  which  catgut  can  be  sterilized, 
but  all  of  them  have  the  disadvantage  of  being  more  or 
less  elaborate  and  of  weakening  it  to  a  considerable  degree. 

Strength. — The  strongest  material  for  its  size  is  silk- 
worm-gut ;   after  it  thread,  then  silk,  and  lastly  catgut. 

Security. — The  knots  of  catgut  are  apt  to  become 
loose  owing  to  its  slippery  surface  and  pulpy  nature.  Silk- 
worm-gut, and  to  a  lesser  extent  thread,  also  share  in 
this  disadvantage.     A  silk  knot  is  the  most  secure. 

Absorbability. — Silkworm-gut  is  never  absorbed.  We 
have  removed  it  apparently  unchanged  at  the  end  of  many 
years.  Silk  and  thread  are  undoubtedly  absorbed,  though 
slowly,  unless  so  thick  that  encystment  by  fibrous  tissue 
occurs  before  the  process  is  complete. 

With  regard  to  silk,  it  is  difficult  to  say  where  the  line 
can  be  drawn  between  absorption  and  encystment,  but 
we  believe  that  No.  4,  at  least,  is  completely  absorbed 
after  about  a  year's  residence  in  healthy  tissue.  Catgut  is 
absorbed  perfectly.  In  areas  of  suppuration  neither  thread, 
silk,  nor  catgut  is  absorbed,  for  the  phagocytic  action  of 
the  tissue  cells  is  in  abeyance. 

Cost. — Simple  linen  thread  is  the  cheapest  of  all,  then 
silk,  after  this  silkworm-gut,  and  lastly  catgut,  which,  owing 
to  the  long  preparation  required,  is  the  most  expensive. 

Conclusions. — For  general  operative  work  we  use 
plaited  China  silk.  Its  strength  is  great,  its  knot  secure, 
its  sterility  can  be  ensured,  its  cost  is  reasonable,  it  can 
be  used  several  times,  and  in  small  sizes  it  is  absorbable. 


24  GYNECOLOGICAL  SURGERY 

We  have  used  thread  and  found  it  good,  except  that  owing 
to  its  great  strength  and  thinness  it  is  liable  to  cut  through 
the  tissues,  and  that  owing  to  its  smooth  surface  the  turns 
of  the  knot  fail  to  bite  and  it  is  apt  to  slip.  We  limit 
the  use  of  silkworm-gut  to  skin  sutures  in  situations,  such 
as  the  perineum,  where  absorption  of  septic  material 
along  the  suture  is  to  be  feared. 

We  have  entirely  given  up  the  use  of  catgut,  believing 
it  to  be  a  bad  and  treacherous  material.  We  have  not 
arrived  at  this  decision  hastily,  but  as  the  result  of  many 
years'  experience  on  our  own  part  and  study  of  that  of 
others.  Every  year,  in  spite  of  the  elaborate  methods 
adopted  to  sterilize  catgut,  a  case  or  two  of  tetanus  due 
to  its  use  is  recorded.  This  accident  has  never  happened 
to  us,  but  we  have  seen  suppuration  follow  its  use  so 
often  that  we  believe  that,  even  though  it  be  sterile,  it  has 
some  peculiar  irritant  effect  on  the  tissues. 

The  whole  merit  claimed  for  catgut  rests  on  its  absorba- 
bility, but  there,  to  our  minds,  lies  one  of  its  chief  dangers, 
for  we  have  seen  quite  a  number  of  cases  in  which  the 
too  rapid  absorption  of  catgut  has  led  to  the  giving  way 
of  the  wound  and  exposure  of  raw  surfaces.  In  addition, 
we  have  knowledge  of  instances  in  which  the  peritoneal  flap 
covering  the  stump  of  the  uterus  after  subtotal  hysterec- 
tomy has  separated,  allowing  the  bowel  to  become  adherent 
and  causing  death  from  intestinal  obstruction.  A  similar 
accident  has  also  happened  to  the  parietal  wound.  The 
knot  tied  by  catgut  is  unsafe,  and  we  have  known 
cases  where  secondary  haemorrhage  has  resulted  from  this 
cause. 

Moreover,  in  a  suppurating  focus  catgut  is  absorbed 
no  more  than  silk,  and  we  have  seen  stitch-sinuses  of 
prolonged  duration  due  to  its  use.  Its  one  advantage 
over  silk  is  that  it  saves  the  patient  the  risk  of  late  suture- 
suppurations  occurring,  say,  six  months  after  the  operation, 
by  which  time  catgut  would  have  been  absorbed.  We 
think  this  a  very  poor  gain  to  purchase  at  such  risks.    The 


SWABS  25 

trouble  of  preparing  catgut  oneself,  and  the  responsibility 
undertaken  if  one  uses  that  sterilized  by  other  people, 
are,  quite  apart  from  its  extra  cost,  further  reasons  why 
we  have  abandoned  its  use. 

SWABS 

Material. — While  sponge  as  a  material  for  swabs  has 
certain  definite  advantages,  such  as  pliability  and  absorp- 
tiveness,  and  certainly  can  be  sterilized,  though  with 
much  trouble,  we  think  that  the  most  suitable  material 
out  of  which  to  make  them  is  Gamgee  tissue  or  absorbent 
wool  covered  with  gauze.  Either  material  is  much  cheaper 
than  sponge,  can  be  boiled  or  steamed,  and  so  sterilized  at 
a  very  short  notice,  can  be  made  into  swabs  of  any  size, 
and  is  easily  obtainable. 

Method  of  making. — For  vaginal  operations  the  swabs 
must  be  small,  about  the  size  of  a  double  walnut,  and  are 
most  conveniently  made  by  tying  up  a  piece  of  wool  of 
that  size  in  an  outer  covering  of  white  gauze. 

For  abdominal  operations  two  sizes  are  required,  one 
large,  12  in.  square,  for  packing  the  intestines,  and  one 
small,  6  in.  square,  for  purposes  of  swabbing.  These  are 
best  made  of  Gamgee  tissue  cut  a  little  larger  than  the  size 
required,  and  the  edges  turned  in  and  sewn  over.  In 
hospital  practice,  for  the  sake  of  cheapness,  pieces  of  wool 
similarly  cut  and  covered  with  white  gauze  sewn  over  at 
the  edges  may  be  used  (Fig.  31). 

Sterilization  of  swabs. — Swabs  are  best  sterilized  by 
steam,  for,  remaining  dry,  their  absorptive  power  is  not 
diminished.  Where  steam  sterilization  is  not  obtainable 
they  should  be  boiled  for  one  hour  and  then  transferred 
to  1 — 1,000  biniodide  of  mercury  solution  until  they  are 
required,  when  they  must  be  wrung  out  in  sterilized  water. 
Wet  swabs  are  much  less  absorptive  than  dry  ones  and 
hence,  in  order  to  work  with  a  practicable  number,  they 
must  be  washed  over  and  over  again  as  the  operation 
proceeds. 


26 


GYNAECOLOGICAL  SURGERY 


Number  required. — For  minor  operations  two   dozen  of 
the  small  swabs  described  will  be  required. 

For  major  vaginal  operations  at  least  three  dozen  are 
necessary,   and  in   addition   two   larger   flat    ones,    similar 

to  those  described  for 
abdominal  operations,  and 
measuring  4  in.  square, 
to  which  a  piece  of  tape 
has  been  sewn,  are  needed 
for  introduction  into  the 
pelvic  cavity  to  prevent 
prolapse  of  the  bowel 
and  omentum  into  the 
vagina. 

For  abdominal  opera- 
tions the  number  required 
will  depend  upon  whether 
the  surgeon  cares  to  have 
the  swabs  wrung  out 
again  and  again  in  the 
course  of  the  operation, 
or  prefers,  once  having 
soaked  a  swab,  to  lay  it 
aside. 

The  first  method  has 
the  advantage  that  a 
smaller  number  is  needed, 
whereby  the  danger  of 
leaving  one  in  the  peri- 
toneal cavity  is  minim- 
ized and  expense  and  labour  are  lessened ;  but,  on  the 
other  hand,  it  involves  more  handling  of  the  swabs  and 
a  greater  risk  of  infection,  whilst  to  perform  the  opera- 
tion as  expeditiously  an  extra  nurse  is  required  to  wring 
them  out. 

The  second  method  requires  a  greater  number  of  swabs, 
but  the  superior  absorptive  power  of  dry  wool  over  wet 


Fig.  31— Swabs. 


STERILIZATION  27 

allows  of  this  being  done  without  necessitating  the  use 
of  an  embarrassing  number. 

We  find  that  for  all  ordinary  abdominal  operations 
fourteen  is  a  sufficient  number,  two  of  the  large  size 
described  and  twelve  of  the  small. 

For  extensive  procedures  such  as  the  radical  abdominal 
operation  for  carcinoma  of  the  cervix,  double  the  number 
of  the  smaller  size  is  needed. 

For  convenience  of  counting,  dry  swabs  should  be 
made  up  in  packets — of  the  large,  containing  two  each  ; 
of  the  small,  six  each.  At  the  outset  of  the  operation  one 
packet  of  the  large  and  two  of  the  small  should  be  opened, 
nor  should  fresh  packets  be  opened  until  each  swab  of 
those  first  put  out  is  thoroughly  soaked  through.  If,  how- 
ever, the  first  method  be  employed,  namely,  to  wash  out 
the  swabs  in  the  course  of  the  operation,  only  eight  are 
required  in  all,  two  of  the  large  size  and  six  of  the  small. 
Of  the  two  methods,  we  much  prefer  the  second. 

The  importance  of  carefully  counting  the  swabs  before 
and  after  the  operation  is  insisted  on  elsewhere. 

METHODS   OF   STERILIZATION 

Sterilization  may  be  accomplished  by  means  of  heat  or 
chemicals. 

STERILIZATION   BY   HEAT 

Heat  will  kill  every  sort  of  known  bacterium  or  spore 
if  the  temperature  is  high  enough  and  the  length  of  appli- 
cation sufficient.  There  are  three  methods  of  sterilization 
by  heat  :    (1)  dry  heat,  (2)  steam,  (3)  boiling  water. 

1.  Dry  heat. — Dry  heat  is  an  unsatisfactory  method. 
It  can  only  be  carried  out  efficiently  by  special  apparatus. 
When  applied  to  dressings,  towels,  or  aprons  in  bulk  it 
takes  a  long  time  before  the  temperature  at  the  centre 
of  the  mass  is  sufficiently  raised,  and  there  is  some  risk  of 
scorching.  Further,  it  spoils  the  temper  of  steel  instru- 
ments.    We  do  not  employ  it. 


28 


GYNAECOLOGICAL  SURGERY 


2.  Steam. — This  is  the  best  method,  especially  when 
applied  superheated.  Steam  sterilizers  of  various  patterns 
are  sold  at  all  instrument  makers',  and  the  pattern  chosen 
will  depend  chiefly  upon  whether  they  are  intended  for 
hospital   or  private  use. 


Fig.  32. — Hospital  sterilizer. 

It  is,  however,  important  that  the  apparatus  should 
be  of  the  "  high-pressure  "  variety  to  ensure  the  steam 
being  driven  into  the  recesses  of  the  mass  of  material  being 
sterilized.  Where  very  large  quantities  of  dressings,  towels, 
etc.,  are  required  to  be  sterilized  at  once,  it  is  also  imperative 
to  be  able  to  exhaust  the  air  from  the  sterilizing  chamber 


STERILIZATION 


29 


before  admitting  the  steam.     In  the  smaller   instruments 
for  use  in  private  work  this  elaboration  is  not   necessary. 

Steam  sterilization  in  hospital  work.  —  For  hospital 
work  the  high-pres- 
sure sterilizer  made  by 
Manlove  and  Alliott, 
or  some  similar  pat- 
tern, will  be  found 
excellent.  (Fig.  32.) 
This  apparatus  can  be 
supplied  with  steam 
drawn  direct  from  the 
boiler  supplying  the 
other  machinery  of 
the  hospital,  or  it  can 
be  worked  by  a  row 
of  gas-jets.  The  me- 
chanism is  simple,  and 
can  be  managed  by 
any  competent  nurse 
after  instruction.  Al- 
though such  a  steril- 
izer could  be  used 
to  sterilize  the  entire 
operative  outfit  at  one 
exposure,  it  is  more 
convenient  in  hospital 
to  reserve  its  use  for 
the  overalls,  towels, 
swabs,  and  dressings, 
leaving  the  instru- 
ments, ligatures,  and  gloves  to  be  separately  sterilized  in 
a  boiler  placed  in  or  adjacent  to  the  operating  theatre. 

Steam  sterilization  in  private  work. — The  surgeon  will 
find  the  possession  of  a  small  high-pressure  steam  sterilizer 
of  the  greatest  convenience  to  him. 

The  pattern  illustrated  in  Fig.   33,  and  made  to  work 


Fig.  33. — Home  sterilizer. 


GYNECOLOGICAL  SURGERY 


at  a  steam  pressure  of  10  lb.,  has  been  found  by  us  to  be 
very  efficient.  It  contains  one  long  drum  (Fig.  33a)  large 
enough  to  take  the  entire  outfit  required  for  the  operation. 
This  drum  is  supplied  with  a  canvas  case  into  which  it 
is  put  after  being  removed  from  the  sterilizer,  so  that 
it  is  conveniently  transported  to  the 
place  where  the  operation  is  to  be 
performed.  The  outfit  required  is 
made  up  as  follows  : — ■ 

Three  overalls  and  three  masks. 

The  rubber  gloves,  drainage- 
tube,  and  catheter. 

The  instruments  and  ligatures. 

Six  towels. 

A  set  of  swabs  (p.  25). 

The  dressings,  a  many -tailed 
binder,  and  a  roll  of  white 
gauze. 

It  is  an  excellent  plan  to  put  up 
the  six  components  of  the  outfit  just 
enumerated  in  separate  muslin  bags 
with  the  name  of  the  contents  in- 
scribed thereon  in  marking-ink. 

The  drum  is  then  packed  in  the 
reverse  order  of  this  list,  and,  the  apertures  in  its  side 
being  opened,  it  is  placed  in  the  sterilizer.  The  reels  of  silk 
should  have  been  previously  soaked  in  water  and  the  gloves 
wetted  inside.  One  hour's  sterilization  at  a  pressure  of 
10  lb.  to  the  square   inch  will  be  sufficient. 

If  instruments  have  been  thus  sterilized,  they  should 
not  be  kept  in  the  drum  for  more  than  twelve  hours,  or 
they  will  rust. 

Though  sterilized  outfits  for  operations  can  be  obtained 
nowadays  from  instrument  makers  in  all  large  towns,  yet 
it  is  a  great  advantage  for  the  surgeon  to  be  "  self-con- 
tained "  in  this  respect.     The  possession  of  the  apparatus 


Fig.  33^. — Drum  of 
home  sterilizer. 


STERILIZATION  31 

described  and  of  a  portable  operating  table  renders  him 
quite  independent  of  the  time  and  place  at  which  his  ser- 
vices may  be  required. 

A  smaller  "  emergency  "  drum,  containing  overalls,  masks, 
towels,  swabs,  and  dressings,  should  always  be  kept  on  hand 
for  those  cases  in  which  instant  action  is  required.  For  such 
a  case  the  instruments  and  gloves  and  silk  are  to  be  boiled 
separately  when  the  surgeon  has  reached  his  destination,  and 
during  the  preparation  of  the  patient  for  the  operation. 

3.  Sterilization  by  boiling. — Boiling  for  half  an  hour 
renders  any  article  sterile.  The  method  is  very  generally 
used  for  instruments,  ligature  material,  and  gloves,  and 
can  be  extended  to  the  swabs  and  towels.  For  overalls 
and  dressings  it  is  not  convenient.  It  has  the  great  advan- 
tage that  it  is  always  applicable.  Ligature  material  after 
boiling  should  be  transferred  to  1 — 40  carbolic  acid  and 
water,  rubber  gloves  to  1 — 1,000  watery  solution  of  bin- 
iodide  of  mercury,  and  swabs  and  towels  to  the  same,  from 
which  they  should  be  carefully  wrung  out  in  sterilized 
water  before  use. 

STERILIZATION    BY   CHEMICALS 

The  use  of  chemicals  for  primary  sterilization  is  limited 
principally  to  the  skin  of  the  operation  area  and  of  the 
hands. of  the  surgeon  and  his  assistants,  but  they  are  also 
usefully  employed  as  a  means  of  maintaining  the  sterility 
obtained  by  heat.  In  some  quarters  it  has  been  the  fashion 
of  late  years  to  belittle  the  use  of  "  antiseptics,"  and  to 
speak  of  "  aseptic  surgery  "  as  though  it  were  something 
quite  apart  from  the  use  of  chemical  means  of  sterilization. 
Such  a  conception  is,  of  course,  untenable  :  no  surgery  is 
"  aseptic  "  which  does  not  in  part  rely  on  the  use  of  "  anti- 
septic" solutions  to  that  end.  For,  leaving  out  of  account 
the  impossibility  of  sterilizing  the  hands  of  the  surgeon 
and  of  his  assistants  without  the  use  of  antiseptic  solutions, 
instruments,  gloves,  towels,  etc.,  though  sterile  when  re- 
moved from  the  steamer  or  boiler,  can  only  remain  so  for  a 


32  GYNECOLOGICAL  SURGERY 

very  short  while  when  exposed  to  the  air.  It  is  true  that 
the  chances  of  dangerous  contamination  from  dust  or  tap- 
water  are  small,  but  that  they  do  exist  is  undeniable. 

We,  therefore,  use  antiseptic  solutions  not  only  for 
preparing  the  hands  and  the  skin  of  the  operation  area, 
but  also  for  the  immersion  of  instruments,  ligatures,  and 
other  appliances. 

Perchloride  and  biniodide  of  mercury. — As  anti- 
septics, the  great  advantages  of  the  salts  of  mercury  are 
the  ease  with  which  they  can  be  carried  and  their  very 
powerful  bactericidal  action.  On  the  other  hand,  they 
are  very  poisonous  and  discolour  steel  instruments,  whilst 
the  perchloride  forms  with  albumin  an  inert  compound. 
They  are  also  decomposed  by  lead,  tin,  and  copper,  so 
that  they  cannot  be  put  into  vessels  made  of  those  sub- 
stances. 

Of  the  two  salts,  the  biniodide  is  much  the  better, 
because  it  does  not  form  a  combination  with  albumin,  is 
not  so  poisonous,  and  does  not  so  readily  blacken  steel. 
It  is  somewhat  more  expensive  than  the  chlorine  salt. 

For  sterilization  of  the  skin  the  best  solution  is  that 
advised  by  Lockwood,  containing  3  parts  of  methylated 
spirit  and  1  part  of  water  in  which  biniodide  of  mercury 
has  been  dissolved  in  a  proportion  of  1 — 500  of  the  mixture. 
Watery  solutions  are  of  no  use  for  this  purpose,  because 
they  do  not  penetrate  the  greasy  surface  of  the  skin.* 

Carbolic  acid. — Carbolic  acid  is  an  inconvenient  chemical 
to  carry  about.  It  does  not  combine  with  albumin,  so  that 
its  properties  are  not  destroyed  by  admixture  with  blood 
or  pus,  neither  does  it  injure  instruments  placed  in  it.  On 
the  other  hand,  it  is  very  irritating  to  the  skin  of  the  hands, 
and  produces  unpleasant  partial  anaesthesia  of  the  finger- 
tips. For  these  reasons  it  has  been  largely  given  up  ;  but 
the  adoption  of  rubber  gloves  obviates  these  disadvantages, 
and  we  have,  therefore,  reverted  to  its  use  for  the  immer- 
sion of   instruments    and  ligatures    after  they   have   been 

*  C  B.  Lockwood,  "Aseptic  Surgery." 


STERILIZATION  33 

sterilized.     For  this  purpose  a  i — 40  solution  is  sufficiently 
strong. 

Alcohol. — We  use  absolute  alcohol  to  sterilize  scalpels 
(see  p.  68).  It  is  also  an  efficient  sterilizer  of  the  skin, 
and  may  be  so  used  when  the  salts  of  mercury  are  not 
available. 

Iodine. — -The  use  of  iodine  to  sterilize  the  skin  has 
been  much  lauded  lately.  It  is  undoubtedly  an  efficient 
bactericide,  and  has  the  further  advantage  of  great  pene- 
trativeness.  On  the  other  hand,  the  skin  of  some  persons 
is  very  intolerant  of  iodine,  and  we  have  known  severe 
dermatitis  set  up  by  its  use.  We  have,  therefore,  only 
employed  it  under  conditions  of  emergency.  We  must 
add  that  we  find  it  the  most  generally  useful  chemical  to 
use  for  vaginal  irrigation  where  a  definitely  sloughing  or 
suppurating  condition  exists  in  that  region. 

Peroxide  of  hydrogen. — Peroxide  of  hydrogen  (10 
volumes)  is  the  best  antiseptic  to  use  for  sloughing  and 
foul  wounds  or  surfaces. 

Lysol  and  crude  sanitas. — These  two  substances  are 
useful  for  douching  when  a  foul  vaginal  discharge  is  present. 
Lysol  should  be  used  in  the  proportion  of  a  teaspoonful 
to  a  quart  of  warm  water,  crude  sanitas  at  a  strength  of  a 
fluid  ounce  to  the  pint.  The  latter  is  a  very  powerful 
deodorant. 

General  remarks  on  the  use  of  antiseptics. — The  uses 
of  antiseptic  substances  may  be  thus  summed  up  : — 

Wounds. — The  application  of  antiseptic  solutions  to 
wounds  is  undesirable  as  a  general  rule.  Healthy  tissues 
are  already  aseptic,  whilst  if  the  tissues  are  diseased  and 
infected  a  solution  sufficiently  strong  to  destroy  the  bacteria 
will  also  kill  or  seriously  damage  the  tissues.  It  is  to  be 
remembered  that  healthy  cells  and  serum  are  in  them- 
selves powerfully  bactericidal,  and  the  greatest  care  should 
be  taken  to  preserve  this  power  intact.  An  exception  to 
the  rule  is  the  case  of  a  wound  covered  by  a  layer  of  necrotic 
and  infected  tissue  to  which  powerful  germicides  may  be 


34  GYNECOLOGICAL  SURGERY 

applied  without  affecting  the  living  cells  underneath.  The 
dressing  of  a  sloughing  abdominal  wound  with  peroxide  of 
hydrogen  or  the  irrigation  of  a  septic  uterine  cavity  with 
strong  mercurial  solution  may  be  cited  as  examples. 

The  skin. — The  difficulty  of  sterilizing  the  skin  is  well 
known.  It  is  probably  impossible  to  destroy  all  the 
organisms  which  are  contained  in  the  epidermis  and  the 
sebaceous  and  hair-follicles.  For  this  reason  the  surgeon 
is  probably  best  advised  who  limits  his  endeavours  to 
sterilizing  the  skin-surface  only.  It  is  possible  by  too  violent 
scrubbing  or  long-continued  fomentation  so  to  sodden  and 
loosen  the  surface  epidermal  cells  that  they  easily  detach. 
Such  particles  conveyed  into  the  wound  may  be  potent 
carriers  of  infection.  A  smooth,  dry  condition  of  the  skin 
is  that  most  favourable  for  surface  sterility.  For  this 
reason  some  think  it  better  to  prepare  the  skin  of  the 
operation  area  within  a  few  hours  of  the  operation,  and 
after  the  final  application  of  spirit  biniodide  solution  to 
keep  it  dry  by  means  of  a  simple  gauze  dressing. 

Similarly  in  regard  to  the  preparation  of  the  surgeon's 
and  assistants'  hands,  care  should  be  taken  not  to  use 
strong  antiseptic  solutions  for  such  length  of  time  as  to 
roughen  the  skin.  In  the  effect  which  chemicals  exercise 
on  the  hands,  personal  idiosyncrasy  counts  for  much. 
Mercurial  salts  are  very  irritating  to  some  skins  if  long 
applied.  We  are  not  in  favour,  therefore,  of  prolonged 
immersion  in  such  solutions.  Two  minutes'  careful  swabbing 
with  spirit  biniodide  solution  after  thorough  washing  is 
probably  sufficient  to  sterilize  the  skin-surface.  The  spirit 
solution  should  then  be  washed  off  in  i — 4,000  watery 
biniodide  solution,  and  the  gloves  put  on  filled  with  the 
same  solution. 

As  we  have  remarked  elsewhere,  the  habitual  use  of 
rubber  gloves  for  all  purposes  of  examination  and  opera- 
tion is  the  best  of  all  safeguards  against  the  presence  of 
virulent  bacteria  in  the  skin. 

The   vagina.- — For  routine  vaginal  douching  a   watery 


SUTURES  35 

solution  of  biniodide  of  mercury,  i — 4,000,  is  the  best. 
In  some  persons  it  sets  up  a  good  deal  of  irritation  after 
a  few  days'  use.  In  such  an  event,  a  simple  boric-acid 
douche  should  be  substituted.  Where  the  douche  is  being 
used  to  cleanse  rapidly  a  foully  infected  vagina,  as  in 
carcinoma  of  the  cervix  and  similar  conditions,  formalin, 
2  per  cent.  ;  iodine,  a  dram  of  the  tincture  to  a  pint  ;  or 
crude  sanitas,  a  tablespoonful  to  the  pint,  will  be  found 
serviceable.  Swabbing  with  peroxide  of  hydrogen,  10 
volumes,  is  also  excellent. 

SUTURES 

In  all  cases  where  a  curved  needle  is  being  used,  we 
believe  it  is  better  to  mount  it  on  a  Spencer  Wells  pressure- 
forceps  rather  than  hold  it  directly  with  the  fingers.  The 
hand    obstructs    the    view,    handling   the    needle    is    liable 


Interrupted  sutures.  /»* ■  (' 


to  prick  the  glove,  and,  as  there  are  certain  situations 
where  the  hand  cannot  be  used,  by  mounting  the  needle  on 
a  forceps  on  every  occasion  the  operator  accustoms  himself 
to  the  most  generally  useful  method.  For  similar  reasons 
needles  should  always  be  withdrawn  either  with  the  dis- 
secting-forceps  in  the  left  hand  or  the  pressure-forceps  in 
the  right. 

Interrupted  sutures.  Simple. — The  advantage  of  the 
interrupted  suture  is  that  if  it  becomes  septic  the  remaining 
sutures  in  its  neighbourhood  are  not  necessarily  affected. 

The  single  interrupted  suture  is  used  for  such  purposes 
as  closing  the  fascia  in  an  abdominal  wound,  for  the  uterine 
wall  in  Cesarean  section,  or  in  perineoplasty  (Fig.  34,  a). 


36  GYNAECOLOGICAL   SURGERY 

Lembert's  (Fig.  34,  b). — This  suture  is  specially  useful 
when  it  is  particularly  necessary  to  get  a  water-tight  or 
gas-tight  suture  line  in  the  peritoneum,  so  that  it  is  the 
suture  chosen  for  the  third  layer  in  intestinal  anastomosis, 
the  second  layer  in  closing  wounds  in  the  bladder,  etc. 

Mattress  (Fig.  34,  c). — In  cases  where  a  suture  is  used, 
not  only  to  approximate  the  parts  but  to  secure  haemos- 
tasis,  a  mattress-suture  will  be  found  the  most  useful  one 
to  employ.  A  good  example  of  its  application  is  the  closure 
of  the  cavity  left  in  the  uterine  wall  after  the  enucleation 
of  a  myoma,  or  in  approximating  the  wedge-like  flaps  of 
the  stump  in  subtotal  hysterectomy. 

Figure-of-8  (Fig.  34,  d). — This  suture  is  very  useful  in 
closing  the  mouth  of  a  small  aperture,  such  as  the  external 
cervical  os  as  a  preliminary  to  total  hysterectomy. 

Cross  suture. — The  cross  suture  is  useful  for  tying  a 
piece  of  silk  to  be  used  as  a  tractor.  The  suture  is  passed 
like  a  mattress-suture  and  the  looped  end  tied  to  the  free 
ends  (Fig.  34,  e). 

Continuous  sutures  (Fig.  35). — A  continuous  suture  has 
the  great  disadvantage  that  if  one  portion  slips  the  whole 
goes,  and  if  one  portion  becomes  septic  the  whole  is  affected. 
Further,  it  leaves  no  room  for  drainage  between  the  suture- 
holes,  so  that  if  there  is  any  oozing  below  it  the  blood  is 
pent  up.  Its  advantages  are,  that  it  secures  a  more  perfect 
approximation  and  hsemostasis,  and  it  is  more  rapidly 
performed  than  a  series  of  interrupted  sutures. 

Simple  (Fig.  35,  a). — This  is  the  most  generally  useful 
continuous  suture,  and  we  use  it  as  a  routine  in  closing 
the  peritoneal  flap  of  a  hysterectomy  and  in  suturing  the 
peritoneum  of  the  abdominal  wound.  It  is  also  used  in 
the  first  layer  of  bowel  suturing. 

Lembert's  (Fig.  35,  b). — This  is  used  in  the  second 
layer  of  bowel  suturing,  and  gives  also  a  very  neat  result 
in  closing  the  peritoneal  flaps  in  hysterectomy  or  in  any 
similar  condition. 

Blanket   (Fig.  35,  c). — This  is  a  pretty  suture,  gives  a 


SUTURES 


37 


very  good  approximation,  and  has  the  advantage  of  securing 
each  stitch  of  the  suture  before  the  next  one  is  passed. 
It  is  only  used  for  skin  surfaces. 

Cushing's  suture  (Fig.  35,  d). — This  modification  of  the 
continuous  Lembert  suture  is  useful  in  certain  circum- 
stances, such  as  attaching  the  anterior  peritoneal  flap  to 
the  back  of  the  cervical  stump  in  subtotal  hysterectomy. 

The  glover's  stitch    (Fig.   35,  e). — This    method    pro- 


Fig.  35. — Continuous  sutures. 


duces  marked  eversion  of  the  wound-edges  and  is  rarely 
indicated.     It  is  a  good  haemostatic  suture. 

Pleating  (Fig.  35,/). — This  suture  is  used  for  puckering 
the  ovarian  ligament  in  ovarian  suspension,  and  for  closing 
the  gap  of  the  broad  ligament  and  approximating  the  stamp 
of  the  round  ligament  to  the  stump  of  the  uterus  in  hys- 
terectomy. 

Purse-string  (Fig.  35,  g), — Useful  for  closing  gaps,  as, 
for  instance,  holes  in  the  broad  ligament. 

Invaginating  (Fig.  35,  h). — Used  in  closing  over  the 
stump  of  the  appendix  and  for  obliterating  small  holes  in 
the  bladder,  etc. 


38  GYNECOLOGICAL   SURGERY 

KNOTS 

The  kind  that  we  usually  employ  is  the  ordinary  granny 
with  three  knots.  It  is  the  simplest  and  quickest,  and 
has  the  great  advantage  that  the  first  knot  can  be  held 
taut  while  the  second  knot  is  being  applied. 

For  the  reef-knot  the  advantage  is  claimed  that  the 
more  it  is  strained  the  tighter  it  becomes.  The  essence 
of  any  knot  used  for  surgical  purposes  is  that  its  first 
knot  should  hold  secure,  and  in  this  the  reef-knot  fails 
to  a  certain  degree  because  it  cannot  so  well  be  held  tight 
while  the  hands  are  being  shifted  to  secure  the  second 
turn.  The  surgeon's  knot  is  the  securest  of  all,  since  the 
first  turn  is  double,  and  therefore  will  not  slip.  We  have 
found  it  to  have  the  disadvantage  of  throwing  more  strain 
on  the  silk,  with  the  result  that  breakage  is  more  likely. 
It  is  important  to  remember  that  with  all  knots  it  is  the 
second  knot  that  usually  breaks  the  silk. 

METHODS   OF   TYING   PEDICLES 

There  are  nine  different  ways  by  which  pedicles  may 
be  tied  (Fig.  36).  Which  special  method  is  followed  depends 
partly  upon  the  idiosyncrasies  of  the  operator,  partly  on  the 
particular  pedicle  to  be  tied,  and  partly  upon  the  time  at 
the  disposal  of  the  operator. 

Method  a  consists  in  surrounding  the  pedicle  with  a 
piece  of  silk  and  tying  it  with  a  suitable  knot.  It  is  the 
simplest  and  quickest,  but  at  the  same  time  it  is  the  most 
dangerous,  because  with  it  the  pedicle  is  most  likely  to 
slip.  If  the  pedicle,  therefore,  contains  any  important 
vessels,  or  if  it  is  much  on  the  stretch,  this  method  should 
not  be  followed.  It  serves  very  well  for  the  cut  ends  of 
the  round  ligaments,  for  pieces  of  omentum,  and  for  slight 
adhesions. 

In  Method  b  the  pedicle  is  transfixed  through  its  centre, 
and  one  of  the  halves  being  tied,  the  ligature  is  then  brought 
back  so  as  to  surround  both  halves  and  tied  again. 


TYING   PEDICLES 


39 


Method  c  is  a  quicker  method  than  Method  b,  and  safer 
than  Method  a.     Its  advantage  over  a  is  that  it  does  not 


Fig.  36. — Methods  of  tying  pedicles  (see  text). 

slip,  and  its  disadvantage  when  compared  with  Method  b  is 
that  the  blood-supply  to  the  portion  of  the  pedicle  distal 
to  the  ligature  is  not  entirely  cut  off  and  an  anastomotic 


40  GYNAECOLOGICAL  SURGERY 

circulation  may  in  certain  circumstances  be  re-established 
to  such  an  extent  as  to  cause  dangerous  oozing,  whilst 
occasionally  even  an  artery  of  some  size  may  be  left  un- 
occluded  in  the  small  portion  of  tissue  outside  the  grip  of 
the  ligature.  This  may,  however,  be  obviated  by  bringing 
back  the  ligature  ends  after  tying  the  knot  so  as  to  include 
the  whole  mass,  and  then  tying  again  in  a  manner  similar 
to  Method  b. 

In  Method  d  the  tissue  to  be  ligatured  is  transfixed  in 
alternate  directions  at  either  edge  and  then  tied — the  so- 
called  mattress-ligature.  It  is  the  most  generally  useful 
method  of  ligature  in  gynaecological  surgery,  and  may  be 
applied  in  various  conditions.  It  effects  a  grip  of  the  enclosed 
tissue  which,  if  the  knot  be  firmly  tied,  is  almost  incapable 
of  slipping.  It  is  employed  chiefly  for  bunching  up  and 
closing  raw  and  oozing  surfaces.  As  applied  to  a  pedicle, 
its  disadvantages  are  those  of  Method  c. 

Method  e  obviates  the  disadvantages  attaching  to 
Method  d.  After  the  mattress-ligature  has  been  tied  with  a 
double  knot,  the  free  ends  of  the  ligature  are  made  to 
encircle  the  whole  pedicle  and  are  again  tied. 

Method  /  is  one  of  the  safest,  the  pedicle  being  trans- 
fixed by  a  double  piece  of  silk,  the  loop  of  which  is  cut, 
making  two  separate  ligatures,  and  each  half  of  the  pedicle 
is  then  tied  separately. 

Method  g  is  an  elaboration  of  Method  e,  a  separate  liga- 
ture being  passed  round  the  whole  pedicle  after  the  two 
halves  have  been  tied.  It  is  a  more  perfect  method  than 
the  other,  because  it  secures  any  small  vessel  which  may 
have  escaped  the  transfixion-ligature  at  the  point  of  trans- 
fixion, while  the  "  surround  "  ligature  alone  is  capable  of 
controlling  the  pedicle  in  the  event  of  either  of  the  other 
two  ligatures  slipping.  Its  disadvantage  is  the  amount  of 
ligature  material  that  is  of  necessity  buried  in  the  tissues. 

Method  h  is  the  most  perfect  of  all  from  the  point  of 
view  of  security,  and  takes  the  longest  time.  It  differs 
from  Method  /  inasmuch  as  the    "  surround  "    ligature   is 


LIGATURES  41 

made  to  transfix  a  small  piece  of   tissue  externally  to  the 
pedicle,  which  prevents  this  structure  from  slipping. 

Where  a  pedicle  is  too  broad  to  be  secured  by  any  of 
the  preceding  methods,  the  chain-ligature  (Method  i)  must 
be  employed.  This  is  the  common  method  of  ligaturing 
omentum. 

LIGATURES 

Ligatures  are  divisible  into  two  classes  :  (1)  occluding 
and  (2)  suboccluding. 

1.  An  occluding  ligature  is  one  that  entirely  cuts  off 
the  blood-supply  to  the  part  distal  to  the  ligature.  The 
different  methods  shown  in  Fig.  36  {a,  b,  e,  j,  g,  h,  i)  are 
examples  of  this  variety.  The  tissue  distal  to  the  ligature 
is  practically  in  that  condition  known  as  white  infarction, 
and  undergoes  anaemic  necrosis.  An  occluding  ligature  has 
certain  definite  advantages  in  that  the  haemostasis  is  not 
only  immediately  perfect,  but,  supposing  the  ligature  holds, 
permanent.  The  likelihood  of  contracting  adhesions  is  much 
less,  or  reduced  to  a  minimum,  because  the  tissues  distal 
to  the  ligature  are  incapable  of  taking  any  active  part  in 
such  an  adhesion.  The  condition  is  comparable  to  that 
which  obtains  when  a  portion  of  foreign  tissue  is  experi- 
mentally implanted  in  the  peritoneum  of  an  animal.  In 
these  cases  it  is  only  after  the  lapse  of  many  weeks  that 
thin  filamentous  adhesions  form  round  the  foreign  substance 
derived  from  the  vascularization  of  the  coagulable  lymph 
thrown  out  by  the  peritoneum.  Moreover,  areas  of  white 
infarction  appear  to  possess  a  certain  immunity  against 
bacterial  infection  as  compared  with  red  infarcts — a  point 
to  which  we  shall  immediately  refer. 

2.  Suboccluding  ligatures  are  those  in  which  the  main 
blood-supply  to  the  portion  distal  to  the  ligature  is  cut  off, 
but  a  track  of  capillary  anastomosis  remains  {see  Fig.  36,  c,  d). 
Of  this  the  mattress-ligature  is  an  example,  and  the  tissues 
distal  to  it  are  in  circumstances  of  red  infarction.  It  occa- 
sionally happens  that  after  a  suboccluding  ligature  has  been 


42  GYNECOLOGICAL  SURGERY 

applied  the  collateral  capillary  circulation  may  develop  to 
such  an  extent  that  oozing  subsequently  starts  from  the 
cut  surface,  and  a  haematoma  is  formed  round  it  in  the 
peritoneal  cavity,  which  may  be  the  starting-point  of  a 
good  deal  of  local  peritonitis  with  some  constitutional 
disturbance.  It  is  owing  to  this  cause  that  certain  patients 
do  not  make  the  rapid  convalescence  which  might  be 
expected.  It  is  further  a  fact  that  the  tissues  in  the  engorged 
and  partially  devitalized  state  which  obtains  in  a  red  infarct 
are  peculiarly  liable  to  bacterial  infection.  As  an  example 
of  this,  the  case  of  the  omentum  may  be  cited,  partial 
strangulation  of  a  portion  of  which  is  soon  followed  by 
very  acute  symptoms,  whereas  the  common  method  of 
ligaturing  omentum  leaves,  distally  to  these  ligatures,  equally 
large  or  larger  areas  of  it  in  a  condition  of  anaemic  necrosis 
without  producing  the  slightest  ill  effects.  Again,  a  reference 
to  general  pathology  will  show  that  whereas  white  infarc- 
tion frequently  occurs  without  any  symptoms  (e.g.  the 
spleen  and  kidney  in  endocarditis),  red  infarction  is  always 
marked  by  acute  pain  and  inflammatory  symptoms.  Thus 
the  tissue  distal  to  a  suboccluding  ligature  is  much  more 
likely  to  become  the  seat  of  an  acute  bacterial  infection 
than  that  distal  to  an  occluding  ligature.  Moreover,  since 
the  cells  of  the  former  are  not  dead  but  merely  damaged, 
adhesion  much  more  readily  occurs.  This  is  rendered  the 
more  likely  if  its  surface  is  surrounded  by  blood  clot  due 
to  oozing  from  the  cut  surface.  Thus  the  use  of  sub- 
occluding  ligatures  may  be  followed  by  plastic  peritonitis 
and  the  formation  of  adhesions  of  such  gravity  that  serious 
symptoms  may  follow. 

From  a  consideration  of  these  various  points  it  is, 
we  think,  obviously  better,  wherever  possible,  entirely  to 
occlude  the  blood  from  the  area  distal  to  a  ligature.  It  is 
for  this  reason  that  the  practice  of  what  appears  an  exces- 
sively massive  and  clumsy  method  of  ligation  of  the  tissue 
leads  to  results  which  on  first  consideration  would  seem 
to  be  unobtainable. 


LIGATURES  43 

Retroperitoneal  haematoma. — By  a  retroperitoneal  hema- 
toma we  mean  an  effusion  of  blood  due  to  a  vein  being 
pricked  or  perforated  by  a  needle  as  a  transfixion-ligature 
is  being  passed  round  some  vessel. 

The  most  likely  stage  for  this  complication  to  occur 
is  when  the  ovarian  or  uterine  arteries  are  being  ligatured, 
when,  if  the  ovarian  or  uterine  vein  is  pricked  or  perforated, 
blood  will  escape  under  the  peritoneum  into  the  cellular 
tissue  at  the  brim  of  the  pelvis  or  in  the  broad  ligament. 
The  accident,  which  is  at  once  recognized  by  the  appear- 
ance of  a  dark-blue  turgid  swelling,  can  on  most  occasions 
be  avoided  if  care  is  taken,  when  ligaturing  the  ovarian 
artery,  to  pull  tight  the  ovarico-pelvic  ligament,  and  pass 
the  needle  through  an  avascular  spot.  Also,  when  liga- 
turing the  uterine  artery  in,  for  instance,  a  subtotal 
hysterectomy,  after  passing  the  needle  through  the  cervical 
tissue,  care  must  be  taken  to  tie  the  vessels  under  the 
forceps  grasping  them,  and  not  to  transfix  the  remains  of 
the  broad  ligament  as  by  a  mattress-suture,  as  it  is  nearly 
always  when  doing  this  that  the  vein  is  injured.  If  such 
an  accident  does  occur,  the  tissue  over  the  effused  blood 
should  be  at  once  grasped  with  forceps  and  another  ligature 
passed.  It  is  sometimes  rather  difficult  to  tell,  after  the 
second  ligature  has  been  tied,  whether  one  has  success- 
fully arrested  the  haemorrhage,  because,  of  course,  the 
blood  which  has  already  escaped  will  still  be  in  situ  ;  great 
care  should,  therefore,  be  taken  during  the  remainder  of 
the  operation  to  examine  at  intervals  the  retroperitoneal 
haematoma,  to  ascertain  whether  it  is  increasing  in  size. 

If  the  vein  is  badly  injured,  the  escape  of  blood  may  be 
rapid  and  marked,  so  that  the  blue  swelling  quickly  spreads 
along  under  the  peritoneum,  distending  the  spaces  of  the 
cellular  tissue.  If  this  occurs,  a  deliberate  search  must  at 
once  be  made  for  the  vessel  by  separating  the  layers  of  peri- 
toneum and  dissecting,  if  necessary,  the  cellular  tissue  till 
the  bleeding-point  is  discovered,  which  may  at  times  be  a 
difficult  and  tedious  matter,  as  the  effused  blood  ploughs 


44  GYNAECOLOGICAL  SURGERY 

up  the   tissues  in  the  neighbourhood,   altering  both   their 
relation  and,  by  the  staining,  their  appearance. 

The  complication  of  a  retroperitoneal  hsematoma  may 
at  times  be  quite  serious.  We  remember  a  case  in  which 
the  effused  blood  from  a  large  ovarian  vein  infiltrated  the 
tissues  up  to  the  perinephric  fat  before  the  haemorrhage 
could  be  arrested. 

DRESSINGS 

Abdominal  section. — It  is  our  practice  to  use  very 
simple  dressings  after  abdominal  section.  The  wound  is 
covered  with  several  layers  of  sterilized  white  gauze,  over 
this  a  large  pad  of  white  sterilized  wool  is  placed,  and  the 
whole  is  kept  in  position  by  a  many-tailed  binder. 

Some  surgeons  prefer  the  use  of  medicated  gauze  and 
wool,  but  we  have  given  them  up  because  they  occasion- 
ally cause  irritation  of  the  skin,  and  moreover  we  believe 
that  infection  of  the  wound  after  it  has  been  closed  is  a 
very  unusual  event,  especially  if  Michel's  clips  are  sub- 
stituted for  penetrating  skin-sutures. 

It  is  in  most  instances  unnecessary  to  change  the  dressing 
until  the  day  on  which  the  stitches  or  clips  are  taken  out, 
but  where  much  oozing  has  occurred,  or  where  drainage 
is  being  employed,  this  rule  must  be  departed  from. 

In  the  first  case,  a  single  change  of  dressing  will  be 
required,  the  skin  when  exposed  being  lightly  swabbed 
over  with  biniodide  spirit  solution  before  applying  the 
new  one. 

In  the  second  case  the  dressing  must  be  changed  as 
often  as  is  necessary,  the  skin  being  cleaned  up  each  time 
this  is  done. 

There  is  always  a  difficulty  in  keeping  the  lower  end 
of  the  wound  covered,  because  the  dressing  and  binder 
tend  to  ride  upwards.  To  prevent  this,  perineal  bands  may 
be  attached  to  the  binder,  but  they  are  uncomfortable  and 
soon  become  soiled.  A  better  method  is  to  fix  the  gauze 
covering  the  wound  by  painting  its  lower  edge  with  collodion. 


DRESSINGS  45 

We  do  not  think  well  of  the  method  of  entirely  collodionizing 
the  wound,  because  it  prevents  the  escape  of  blood  and 
serum,  and  so  creates  a  possible  bacterial  nidus. 

It  is  probable  that  could  the  surface  of  a  carefully 
closed  wound  be  protected  from  chafing  and  injury,  it  would 
heal  admirably  exposed  to  the  air,  for  all  dressings  have 
the  disadvantage  of  preventing  drying  by  evaporation, 
a  moist  surface  being  particularly  favourable  to  the' growth 
of  bacteria. 

Yaginal  operations. — For  all  operations  on  the  vulva 
and  perineum,  a  T-bandage  is  required  to  retain  the 
dressing.  This  should  consist  of  sterilized  gauze  covered 
with  a  pad  of  sterilized  white  wool.  It  will  have  to  be 
changed  every  time  the  patient  passes  water  or  defalcates, 
and  also  after  each  vaginal  douche  (if  such  be  given)  and 
each  examination. 

The  use  of  medicated  dressings  is  contra-indicated, 
because  the  vulval  surface,  especially  in  some  persons,  is 
very  intolerant  of  chemicals,  and  readily  becomes  irritated 
and  sore. 

After  operations  on  the  vagina,  cervix,  or  uterus,  if 
vaginal  packing  is  indicated  it  is  best  done  with  simple 
sterilized  gauze.  It  should  be  removed  in  twenty-four 
hours,  and  not  replaced,  after  which  the  vagina  should  be 
douched  three  times  a  day  with  a  weak  antiseptic  solution, 
such  as  biniodide  of  mercury,  i — 4,000  ;  lysol,  1  drachm 
to  a  quart ;  or  boric  acid,  1  drachm  to  a  pint.  The  first 
two  solutions,  after  being  used  for  some  days,  sometimes 
cause  a  degree  of  irritation.  The  patient  should  always 
be  nursed  in  the  sitting  posture  to  promote  drainage. 

Where  some  foul  condition  of  the  genital  canal  exists 
before  the  operation,  such  as  a  sloughing  uterine  polypus, 
it  is  better  to  pack  the  vagina  with  iodoform  gauze  instead 
of  plain  sterilized  gauze. 

For  intra-uterine  packing,  simple  sterilized  gauze  is 
the  best,  except  in  cases  of  acute  intra-uterine  sepsis, 
when  iodoform  gauze  should  be  substituted.     Intra-uterine 


46  GYNECOLOGICAL  SURGERY 

packing  should  be  withdrawn  permanently  in  twenty-four 
hours. 

DRAINAGE 

When  to  drain. — The  occasions  on  which  drainage  is 
to  be  employed  after  abdominal  sections  for  pelvic  disease 
is  a  matter  for  nice  discrimination.  For,  on  the  one 
hand,  failure  to  take  this  precaution,  when  called  for,  may 
lead  to  death,  severe  illness,  or  a  second  operation  for 
retained  pus  ;  on  the  other  hand,  unnecessary  drainage, 
while  probably  never  a  cause  of  severe  infection  under 
modern  conditions,  may  induce  discharge  where  none 
would  have  otherwise  existed,  prolongs  convalescence,  and 
tends  to  leave  a  weak  spot  in  the  scar. 

The  mere  presence  of  pus  in  the  pelvis  is  not  a  sufficient 
indication  for  drainage,  and  this  is  particularly  true  of 
cases  of  pyo-salpinx,  for  in  a  large  number  of  such  cases 
investigated  for  us  at  the  Middlesex  Hospital,  in  which  the 
pus  had  been  sequestered  for  a  considerable  time,  no  organ- 
isms could  be  isolated.  Such  sterile  pus  is  often  extremely 
evil-smelling,  so  that  fetor  is  no  indication  for  drainage. 

On  the  other  hand,  pus  primarily  formed  in  the  peri- 
toneum, such  as  occurs  round  necrotic  tumours,  the  inflamed 
appendix,  or  a  suppurating  hematocele,  probably  contains 
active  streptococci  or  colon  bacilli,  and  the  same  holds 
good  for  the  contents  of  inflamed  ovarian  cysts,  suppu- 
rating solid  tumours,  or  a  recent  pyo-salpinx.  Under  such 
conditions  the  operation  area  must  certainly  be  drained. 

As  a  general  rule,  it  may  be  laid  down  that  where  the 
peritoneum  covering  the  pelvic  organs  and  the  coils  of  gut 
in  relation  to  them  shows  signs  of  acute  or  subacute  peri- 
tonitis with  definite  reddening  and  injection,  drainage 
should  be  employed,  whether  pus  be  present  or  not ;  but 
where,  even  in  the  presence  of  a  large  collection  of  pus, 
the  peritoneum  is  pale,  uninjected,  and  inert  in  appearance, 
drainage  is  not  necessary. 

There    are    certain    cases    in   which    a    drain   is    advan- 


DRAINAGE  47 

tageously  inserted  for  a  short  time,  i.e.  cases  in  which 
future  suppuration  or  extravasation,  though  not  likely,  is 
at  least  possible. 

Thus,  after  resection  of  intestine,  if  there  be  some 
doubts  as  to  the  soundness  of  the  suture-line  a  small  drain 
may  be  inserted  down  to  the  involved  coil  and  removed 
after  the  end  of  forty-eight  hours ;  or,  again,  in  certain 
cases  of  hematocele,  where,  by  reason  of  the  preoperative 
presence  of  fever,  infection  of  the  pelvic  peritoneum  appears 
likely  to  have  occurred,  it  is  a  wise  precaution  to  insert  a 
small  drain  for  a  couple  of  days.  Drains  left  in  for  this 
period  form  a  track  along  which  the  products  of  suppura- 
tion or  of  extravasation,  taking  place  later  on,  may  find 
a  way. 

Abdominal  or  vaginal  drainage. — It  would  at  first 
sight  appear  that  a  vaginal  drain  should  have  certain 
advantages  over  an  abdominal  one,  partly  because  it 
necessitates  no  weakening  of  the  abdominal  wound,  and 
partly  because  of  its  dependent  position.  Of  these  points 
the  first  is  true,  but  in  regard  to  the  second  there  can  be 
no  doubt  that  vaginal  drainage  is  less  efficient  than  abdo- 
minal, although  the  current  in  the  latter  case  is  against 
the  force  of  gravity ;  for  where  both  abdominal  and 
vaginal  drainage  are  simultaneously  employed,  the  dis- 
charge is  much  freer,  and  continues  much  longer  from  the 
upper  than  from  the  lower  opening. 

The  reasons  for  this  are  not  entirely  obvious,  but  it 
may  be  remarked  that  an  opening  into  the  top  of  the  vagina 
is  placed,  not  at  the  bottom  of  the  pouch  of  Douglas,  but 
well  up  on  its  anterior  wall,  so  that  it  does  not  really  directly 
drain  the  lowest  portion  of  the  pelvic  cavity  ;  and  further, 
that  there  is  a  great  tendency  for  this  opening  to  close 
prematurely,  either  by  rapid  adhesion  to  a  prolapsed  coil 
of  sigmoid  colon  or,  as  frequently  happens  after  total 
hysterectomy,  by  the  bladder  falling  back  and  adhering  to 
the  rectum. 

A  vaginal  drain  is  also  not  easy  to  keep  in  position, 


48  GYNECOLOGICAL   SURGERY 

is  impossible  to  maintain  clean,  troublesome  to  take  out, 
and  difficult  to  reinsert.  On  these  accounts  we  consider 
that  for  drainage  of  the  pelvic  peritoneal  cavity  the  abdo- 
minal route  is  the  best. 

Drainage  material.— After  giving  a  long  trial  to  drainage 
by  gauze  wicks,  we  have  abandoned  the  method  in  favour 
of  the  soft  rubber  tube.  It  is  questionable  to  our  minds 
whether  a  gauze  wick  really  does  assist  the  flow  of  fluid 
through  an  opening,  even  when  lightly  packed.  Certainly, 
when  tightly  packed  it  actually  obstructs  it,  and  its  with- 
drawal is  always  followed  by  a  gush  of  pent-up  discharge. 
A  gauze  wick  leaves  a  track  along  which,  after  its  removal, 
fluid  may  subsequently  make  its  way,  and  this  is  its  solitary 
virtue. 

Tube  drainage  has  the  advantage  of  acting  as  an 
immediate  indicator  of  extravasation  of  blood,  urine,  or 
intestinal  contents,  if  that  occurs,  and  the  surgeon  is  at 
once  apprised  of  the  disaster.  Gauze  drainage,  on  the 
other  hand,  is  very  misleading,  for  bright  blood  filtering 
up  it  very  often  comes  from  the  edges  of  the  abdominal 
wound,  whilst  extensive  intraperitoneal  bleeding  may  be 
merely  indicated  by  sero-sanguinolent  discharge,  owing 
to  the  blood  corpuscles  becoming  entangled  in  the  meshes 
of  the  material.  And,  further,  extravasated  urine  filters 
up  so  slowly  that  its  small  quantity  diverts  the  mind  from 
the  possibility  of  a  leak  in  the  urinary  apparatus  ;  and  we 
know  of  a  case  that  was  lost  from  this  cause. 

Management  of  the  drain. — Where  drainage  is  em- 
ployed merely  as  a  precautionary  measure,  and  not  of 
necessity,  we  use  a  piece  of  J-in.  tube  and  withdraw  it  in 
from  twenty-four  to  forty-eight  hours.  For  regular  drainage, 
f-in.  tube  should  be  employed,  or,  what  is  perhaps  better, 
a  small  sheaf  of  three  or  four  |-in.  tubes. 

The  tube  or  tubes  should  be  left  in  situ  for  at  least 
forty-eight  hours,  and  may  then  be  daily  pulled  up  a  little 
way  and  the  excess  cut  off.  If  the  discharge  is  only  serous, 
the  tube  should  be  entirely  withdrawn  when  the  discharge 


DRAINAGE  49 

is  reduced  to  a  small  quantity.  It  should  not  be  left  beyond 
this  time,  as  its  presence  may  excite  a  suppuration  which 
would  not  otherwise  have  taken  place.  If  the  discharge 
is  purulent,  the  withdrawal  of  the  tube  should  be  post- 
poned for  at  least  five  days,  i.e.  till  a  definite  track  has 
formed  down  which  it  is  easy  to  repass  the  tube  after 
cleansing,  or  to  substitute  one  of  a  somewhat  smaller 
calibre.  If  a  sheaf  of  tubes  has  been  used,  one  may  be 
withdrawn  at  a  time. 

The  tube  must  on  no  account  be  left  in  situ  too  long, 
since  its  pressure  may  cause  perforation  of  damaged  intes- 
tinal wall.  It  is  a  mistake  to  irrigate  the  abscess  cavity 
through  the  drainage-tube,  as  a  rule.  If  free  drainage  has 
been  provided,  irrigation  will  do  no  further  good,  and  may 
do  harm  by  inhibiting  the  activity  of  the  tissue  cells. 
One  frequently  sees  sinuses  that  have  been  kept  open 
solely  by  misapplied  zeal  in  this  direction. 

In  conclusion,  it  is  a  matter  of  importance  to  prevent 
the  tube  from  slipping  into  the  abdominal  cavity.  For 
abdominal  drainage,  transfixion  with  a  safety-pin  is  the 
most  generally  useful  method,  but  in  vaginal  drainage  the 
tube  must  be  lightly  fixed  to  the  cut  edge  of  the  vaginal 
wall  by  a  piece  of  No.  i  silk.  This  will  yield  in  a  week 
and  leave  the  tube  free. 

FIXATION   OF   TISSUES  AND   PRESERVATION 
OF   SPECIMENS 

Fixation. — It  often  happens  that  a  surgeon  will  wish 
to  remove  a  portion  of  tissue  for  microscopical  purposes. 
The  piece  removed  should  be  placed  forthwith  in  "  acetic 
alcohol  "  (absolute  alcohol  2  parts,  pure  glacial  acetic  acid 
1  part),  in  which  it  may  remain  from  half  an  hour  to 
twenty-four  hours  ;  after  this  it  should  be  transferred  to 
absolute  alcohol,  in  which  it  may  be  kept  until  it  is  con- 
venient to  imbed  it.  This  is  a  very  rapid  method  of  fixing, 
and,  when  necessary,  small  pieces  of  tissue  may  be  cut  in 
paraffin,  stained,  and  examined  within  four  hours  of  removal. 


50 


GYNECOLOGICAL  SURGERY 


If  a  quicker  examination  than  this  is  required,  the  tissue 
had  better  be  cut  direct  with  a  freezing  microtome. 

Method  for  preserving  specimens. — We  have  found  the 
most  satisfactory  way  to  fix  and  mount  specimens  is  that 
invented  by  Jores  and  modified  by  Rowntree,  as  follows 
(Arch.  Middx.  Hosp.,  vol.  x.)  : — 

[■        i.  Immerse  the  specimen  for  24 — 48  hours  in 

Sodium  sulphate  .  .  .  .  .  .      20  grm. 

Sodium  chloride  .  .  .  .  . .      10       ,, 

Magnesium  sulphate     .  .  .  .  .  .      20 

Formalin.  .  .  .  .  .  .  .  .  .      50  c.c. 

Water       .  .  .  .  .  .  .  .       to  1,000     ,, 

2.  Immerse  the  specimen  for  12- — 24  hours  in 

50  per  cent,   naphtha-free  methylated  spirit. 

3.  Immerse  the  specimen  for  4 — 6  hours,  until  the 

colour  returns,  in 
Pure  naphtha-free  methylated  spirit. 

4.  Immerse  the  specimen  for  2 — 3  days  in 

Sodium  acetate .  .  .  .  .  .  .  .      20  grm. 

Glycerine  .  .  .  .  .  .  .  .    500  c.c. 

Water       .  .  .  .  .  .  .  .  .  .    500     ,, 

5.  Immerse  the  specimen  for  2 — 3  days  in  pure  glycerine. 

6.  Mount  the  specimen  in  liquid  paraffin. 


CHAPTER    III 
OPERATING  THEATRE  AND  APPOINTMENTS 

OPERATING    SUITE 

In  most  cases  the  surgeon  will  have  to  make  the  best 
of  the  theatre  he  finds  at  his  disposal  when  he  is  first 
appointed  to  the  staff.  Operations  are  daily  performed 
with  the  greatest  success  in  the  most  unfavourable  cir- 
cumstances, and  the  surgeon  must  always  remember  that 
the  results  of  his  work  will  be  due  to  his  own  forethought 
and  skill  rather  than  to  a  perfect  theatre  and  its  appoint- 
ments. 

It  is,  however,  more  encouraging  for  a  surgeon  to 
operate  amidst  surroundings  as  perfect  as  may  be,  and 
we  will  now  indicate  what  in  our  opinion  these  should  be. 
The  operation  suite  should  consist  of  seven  rooms  :  the 
operating  theatre,  the  anaesthetic  room,  the  surgeon's 
dressing-room,  the  immediate-preparation  room,  the  dis- 
robing room,  the  sterilizing  room,  and  the  nurses'  store- 
room. 

Theatre  :  light.  ■ —  The  daylight  should  be  admitted 
through  a  window  having  a  northern  aspect.  This  window 
should  occupy  the  greater  part  of  the  north  side  of  the 
theatre,  and  terminate  3  ft.  from  the  floor.  The  upper 
edge  should  be  continued  as  a  sloping  skylight  for  12  ft. 

Artificial  light  is  always  a  difficulty,  and  the  method 
chosen  must  depend  upon  the  funds  in  hand.  The  ideal 
method  is  to  have  the  electric  light  with  linolyte  lamps 
arranged  right  round  the  walls  of  the  room  in  such  a  way 
that,  whilst  avoiding  an  unpleasant  glare  in  the  eyes  of 
the  surgeon  and  his  assistants,  an  even  and  comparatively 
shadowless   light   suffuses   the   whole   theatre. 

5i 


52  GYNAECOLOGICAL  SURGERY 

In  addition,  a  hand-lamp  will  be  required,  attached 
to  a  wall-plug  which  should,  of  course,  lie  flat  with 
the  wall. 

Floor. — The  floor  should  be  impermeable  and  capable 
of  being  washed,  perfectly  smooth,  and  not  subject  to 
roughing  from  traffic . 

Walls.— The  walls  should  be  covered  with  parian  cement, 
and  then  painted  with  as  many  coats  as  necessary  of 
enamel.  The  surface  resulting  is  very  hard,  perfectly 
smooth,  and  capable  of  being  washed  or  steamed. 

Ceiling. — A  part  of  the  roof  of  the  theatre  should  be 
made  use  of  for  a  skylight,  set  at  an  oblique  angle  to  the 
window  and  continuous  with  it.  The  rest  of  the  roof 
should  slope  down  from  the  highest  part  of  the  skylight, 
and  the  ceiling  should  be  made  of  a  substance  sufficiently 
smooth  and  dense  to  bear  thorough  washing.  No  cross 
beams  or  rods  should  be  permitted,  as  they  collect  dust. 
A  flat  ceiling  should  be  avoided,  for  moisture  condensed 
on  it  drips  downwards.  All  the  angles  between  the  walls, 
ceiling,  and  floor  should  be  rounded  and  made  smooth, 
and  the  frames  of  the  doors  and  windows  should  be  flush 
with  the  walls. 

Shelves. — Shelves  should  not  be  fixed  in  the  theatre,  but 
in  an  adjoining  room,  and  should  be  so  arranged  that  the 
bottles  they  support,  containing  the  antiseptic  solutions, 
can  be  seen  through  a  glass  panel  in  the  wall  through 
which  the  india-rubber  tubes  to  deliver  the  fluid  should 
pass. 

Operation  table — A  most  excellent  and  simple  table 
for  hospital  use  is  one  devised  by  Herbert  Spencer 
(Fig.  29).  It  is  the  type  we  use  both  at  the  Middlesex 
Hospital  and  at  the  Chelsea  Hospital  for  Women. 

Other  tables. — Four  other  tables  are  required:  1, 
anaesthetist's  table ;  2,  instrument  table ;  3,  swab  table ; 
4,  additional-material  table.  All  of  them  should  be 
made  of  glass  and  vitreous  enamelled  iron,  and  should 
be  mounted  on  castors. 


c 


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a 
o 

a> 

O 

6 


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54 


GYNECOLOGICAL  SURGERY 


16  SC 
Fig.  37a. — Glass  bowls. 


Basins   and   bowls. — All   basins   and    bowls    should    be 
made   of    porcelain    enamel,    which   does    not   chip   except 

under  the  roughest 
usage,  and  which  can 
be  boiled.  For  im- 
mersing the  arms  as 
well  as  the  hands, 
long  glass  bowls  car- 
ried in  an  enamelled 
iron  frame  are  re- 
quired. Two  of  these 
should  be  placed  in 
the  theatre  within 
convenient  reach  of 
the  operating  table 
(Fig.  37a). 

Douche-pan. — It 
is  necessary  in  vag- 
inal operations  to 
have  some  recep- 
tacle into  which  the 
douche  -  fluid  may 
run  as  it  leaves 
the  vagina.  Kelly's 
india-rubber  pad  is 
generally  used  for 
this  purpose,  but 
for  hospital  work  it 
is  far  inferior  to  a 
metal  douche  -  pan 
devised  by  Dr. 
Stuck,  an  old  resi- 
dent officer  at  the 
Chelsea  Hospital  for 
Women.  This 
douche-pan  has  se- 
Fig.  37b—  Stuck's  douche-pan.  veral     advantages  : 


OPERATING   SUITE  55 

it  can  be  detached  from  the  table  and  sterilized  between 
the  operations  ;  whilst  allowing  the  douche  -  water  and 
blood  to  escape  into  the  pail  below,  it  retains  any  pieces 
of  growth  or  mucous  membrane  that  may  have  been  de- 
tached ;  it  will  serve  as  a  tray  to  hold  instruments  ;  and, 
lastly,  it  collects  the  escaping  douche  much  more  effi- 
ciently than  the  Kelly's  pad.     (Fig.  376.) 

Anaesthetic  room. — This  room  need  not  necessarily 
open  into  the  theatre  ;  indeed,  it  is  better  that  there 
should  be  a  passage  between.  It  should  contain  a  cup- 
board in  which  the  anaesthetic  drugs  and  apparatus  may  be 
stored,  and  a  table  on  which  the  anaesthetic  register  can  be 
placed. 

Surgeons'  dressing  -  room. — This  should  contain  wash- 
basins and  a  bath,  and  be  in  communication  with  a  lavatory. 
It  should  open  into  the  immediate-preparation  room. 

Immediate  preparation  room. — In  this  room  the  final 
preparations  of  the  surgeon  and  his  assistants  are  made, 
and  the  instruments  and  ligatures  sterilized. 

There  should  be  no  wash-basins,  but  one  long  porcelain 
trough  into  which  water  is  delivered  by  four  rose  jets 
controlled  by  elbow-taps,  and  so  arranged  that  cold,  hot, 
or  tepid  water  can  be  delivered  at  will.  Above  the  trough 
a  glass  shelf  should  be  fixed  to  hold  the  soap  and  nail- 
brush boxes.  The  room  should  contain  a  metal  table 
to  hold  the  drums  containing  the  sterilized  overalls.  It 
should  have  fixed  in  it  a  sterilizer  (if  possible  worked  by 
steam)  for  the  boiling  of  instruments,  ligatures,  etc.,  and 
all  other  things  which  cannot  be  conveniently  sterilized 
en  masse  by  the  main  sterilizing  plant  contained  in  the 
main  sterilizing  room.  A  shelf  for  holding  the  large  glass 
jars  containing  antiseptic  solutions  has  been  already  men- 
tioned, and  an  apparatus  for  the  delivery  of  hot  and  cold 
sterilized  water  should  also  be  fixed  in  this  room.  This 
immediate-preparation  room  should  lead  directly  into  the 
theatre  and  also  into  the  sterilizing  room. 

Sterilizing  room. — This  room  should  contain  a  Manlove 


56  GYNECOLOGICAL  SURGERY 

and  Alliott  high-pressure  sterilizer  for  dressings,  and  a  dish- 
boiler  large  enough  to  take  all  bowls,  basins,  dishes,  etc., 
and  they  should  be  worked  by  high-pressure  steam  if 
possible.  Here  also  should  be  kept  the  instrument  case, 
made  of  glass  and  metal  with  a  sloping  roof.  This  room 
should  lead  direct  into  the  immediate-preparation  room, 
and   into   the   nurses'   store-room. 

Nurses'  store-room. — In  this  room  the  nurse  can  re- 
move her  aprons  and  cap  and  wash  her  hands  preparatory 
to  her  final  preparation,  which  should  take  place  in  the 
immediate-preparation  room.  It  should,  therefore,  contain 
wash-basins,  besides  cupboards  in  which  can  be  kept  over- 
alls, towels,  sheets,  mackintoshes,  dressings,  and  all  other 
theatre  stores.  It  should  be  furnished  with  a  large  table 
and  some  chairs  ;  and  here  all  cutting  out,  sewing,  and 
other  necessary  work  should  be  done.  The  room  should 
be  in  communication  with  the  sterilizing  room. 

Disrobing  room. — It  has  always  seemed  to  us  that  one 
of  the  chief  defects  of  modern  operating  suites  is  the  failure 
to  provide  a  room  wherein  the  surgeon  and  his  assistants 
may  remove  their  soiled  overalls,  gloves,  and  masks,  and 
into  which  all  contaminated  articles,  such  as  soiled  towels, 
basins  containing  blood,  pus,  tumours,  or  the  dirty  instru- 
ments, can  be  removed.  As  a  rule,  the  immediate-pre- 
paration room  has  to  serve  for  this  purpose — obviously  a 
grave  fault  of  arrangement.  The  disrobing  room  should 
contain  a  washing-trough  for  the  hands,  a  second  trough 
for  washing  the  instruments  and  basins,  a  sink  for  con- 
taminated fluids,  a  metal  receptacle  on  wheels  for  the 
soiled  linen  which  is  to  be  washed,  and  one  for  all  articles 
to  be  destroyed.  This  room  should  lead  immediately  off 
the  operating  theatre,  and  should  communicate  with  the 
main  passage  and  the  surgeons'   dressing-room. 

Visitors. — The  accommodation  of  onlookers  at  gynae- 
cological operations  is  always  a  matter  of  difficulty,  because 
unless  the  spectator  is  quite  close  it  is  difficult  to  see  much. 
In  hospitals  where  a  large  number  of  students  have  to  be 


THE   STAFF  57 

accommodated  some  sort  of  a  gallery  or  stand  is  a  necessity. 
Visitors  allowed  on  the  floor  must  wear  overalls,  which 
should  be  supplied  from  the   nurses'   room. 

STAFF   OF   THE    OPERATING   THEATRE 

In  ideal  circumstances  in  hospital  practice  the  surgeon, 
in  our  opinion,  requires,  when  operating,  a  staff  of  six,  if 
everything  is  to  run  perfectly  smoothly  and  the  technique 
is  to  be  as  aseptic  as  it  is  possible  to  make  it.  In  private 
operations  this  number  is  rarely  possible,  and  four  is  the 
most  that  one  can  usually  obtain.  More  than  six  is 
unadvisable,  for  the  greater  the  number  of  people  who 
are  touching  the  instruments  and  the  operation  area,  the 
greater  chance  will  there  be  of  septic  infection.  The  safest 
plan  is  to  reduce  the  number  of  the  staff  to  the  most 
efficient  minimum,  for  below  this  the  risk-curve  rises, 
because  at  one  moment  some  of  the  assistants  will  have 
to  perform  duties  which  cannot  be  in  keeping  with  surgical 
cleanliness,  and  at  the  next  moment  they  will  be  called 
upon  to  perform  duties  which  ought  to  be  so,  and  thus 
the  aseptic  technique  breaks  down. 

In  hospital  the  staff  should  consist,  besides  the  surgeon, 

of— 

i.  First  assistant. 

2.  Second  assistant. 

3.  Anaesthetist. 

4.  Swab  nurse. 

5.  Instrument  nurse. 

6.  General  nurse. 

Some  surgeons  dispense  with  the  swab  and  instrument 
nurses,  and  do  this  work  themselves  with  the  aid  of  the 
first  or  the  first  and  second  assistants.  Such  an  arrange- 
ment will  serve  for  minor  operations,  and  in  private 
work  often  has  to  suffice  for  any  operation,  but  for  major 
operations  it  is  a  drawback  to  the  operator  to  take  on 
duties  other  than  those  of  the  operation  itself.  If  dry 
swabs  are  used,  the  swab  nurse  is  not  a  necessity,  because 


58  GYNECOLOGICAL  SURGERY 

no  wringing  out  is  required.  Nevertheless,  she  may  be 
usefully  employed  to  keep  count  of  their  number  and 
exercise  a  general  supervision  over  their  use. 

The  general  arrangement  of  the  theatre  during  an 
operation  is  indicated  in  Fig.  38.  « 

DUTIES    OF   THE   STAFF 

The  surgeon,  his  assistants,  and  the  instrument  and 
swab  nurses  should  not  touch  any  article  liable  to  have 
been  infected  after  the  time  they  have  prepared  for  the 
operation. 

First  assistant. — A  good  first  assistant  is  made,  not 
born.  His  duties  are  next  to  the  operator's  in  importance, 
and  can  only  be  perfectly  learnt  by  a  long  apprenticeship 
thoughtfully  served.  Self-abnegation  should  be  his  key- 
note :  he  should  neither  offer  advice  when  it  is  unasked  for, 
nor  take  upon  himself  any  of  the  manipulations  proper 
to  the  surgeon,  unless  requested  to  do  so  ;  he  should  be 
silent,  watchful,  and  keep  his  head  and  hands  out  of  the 
wound.  He  should,  of  course,  direct  the  attention  of  his 
chief  to  any  point  which  the  latter  has  obviously  over- 
looked. His  position  in  an  abdominal  operation  is  on  the 
left  side  of  the  patient,  opposite  to  the  operator,  but  in 
a  vaginal  operation  he  is  on  the  right  side,  so  that  his  right 
hand  is  at  the  service  of  his  chief.  One  of  his  main  objects 
should  be  to  give  the  operator  as  clear  a  view  as  possible 
by  properly  retracting  the  wound,  and  in  this  regard  it 
may  be  mentioned  that  the  assistant  is  apt  to  forget  that 
the  structures  on  the  right  side  of  the  middle  line  are,  by 
reason  of  the  position  of  the  operator,  least  visible  to  the 
latter.  He  should  concentrate  his  mind  on  how  best  to 
facilitate  the  actions  of  the  surgeon,  whether  he  is  in  agree- 
ment with  him  or  not.  These  qualities  are  quite  distinct 
from  those  required  by  the  operator  himself ;  and  indeed 
many  good  surgeons  are  hopeless  assistants,  and  conversely, 
of  course,  a  good  assistant  may  be  a  poor  operator. 

Second    assistant. — This      assistant's     position     in     an 


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60  GYNECOLOGICAL  SURGERY 

abdominal  operation  is  at  the  right  hand  of  the  operator. 
In  a  vaginal  operation  he  stands  on  the  patient's  left  side. 
His  duties  consist  chiefly  in  anticipating  the  wishes  of  the 
operator  in  regard  to  the  instruments  he  requires,  to  do 
which  he  should  studiously  acquire  a  knowledge  of  the 
technique  usually  followed  in  abdominal  operations.  It 
is,  therefore,  a  post  of  the  greatest  educational  value  to 
those  who  intend  to  follow  a  surgical  career.  The  second 
assistant  must  also  be  ready  to  lend  help  in  retracting 
the  wound-edge  on  his  side,  and  to  carry  out  such  other 
duties  as  the  surgeon  may  direct. 

Anaesthetist. — The  anaesthetist  is  responsible,  of  course, 
for  the  choice  of  the  anaesthetic  and  its  administration,  and 
must  inform  the  surgeon  when  at  any  time  the  patient's 
condition  seems  to  be  getting  seriously  worse.  The  anaes- 
thetist should  not  allow  himself  to  be  influenced  in  any 
way  by  remarks  of  the  surgeon  as  to  changing  the  anaes- 
thetic, "  pushing  it,"  etc.,  if  the  patient's  life  is  likely  to 
be  endangered  thereby,  for  should  the  patient  die  whilst 
under  the  influence  of  the  anaesthetic,  the  responsibility 
will  rest  upon  him  and  not  upon  the  surgeon. 

If  the  operating  table  is  moved  by  a  screw  or  any  other 
apparatus  near  the  patient's  head,  the  anaesthetist  will 
raise  the  table  to  the  angle  required. 

Instrument  nurse. — The  instrument  nurse  or  theatre 
sister  will  be  responsible  for  the  proper  sterilizing  of  all 
instruments,  ligatures,  sutures,  dressings,  surgeons'  and 
nurses'  overalls,  masks,  towels,  swabs,  and  gloves  ;  also 
for  the  preparation  of  antiseptic  solutions  for  the  hands. 
Her  place  during  the  operation  is  at  the  instrument  table, 
where  she  threads  the  needles  and  bands  them  to  the 
second  assistant  as  he  may  ask  for  them. 

Swab  nurse. — The  swab  nurse  and  the  general  nurse 
will  get  the  patient  ready  on  the  table,  fixing  her  legs  if 
necessary,  tucking  the  nightdress  up,  and  removing  the 
binder  so  that  the  operation  area  is  only  covered  by  the 
dressing.     The  swab  nurse  will  then  finish  the  preparation 


STAFF  OF   OPERATING   THEATRE  61 

of  her  hands,  after  which  she  will  be  ready  to  hand  the 
swabs  from  the  tin  in  which  they  have  been  sterilized,  or 
wash  them  if  wet  ones  are  being  used.  In  both  cases  she 
may  be  held  responsible  for  the  number  used,  although  the 
surgeon  should  satisfy  himself  before  he  closes  the  abdominal 
wound  that  there  are  none  missing.  If  dry  swabs  in  large 
numbers  are  being  used,  the  nurse  may  find  it  difficult  to 
tell  the  surgeon  at  once  when  he  asks  her  how  many  swabs 
she  requires  to  make  her  number  correct,  and  she  will 
find  it  easier  on  this  account  to  have  the  swabs  done  up 
in  packets  of  six  before  they  are  sterilized,  and  the  total 
number  of  swabs  in  the  box  written  down  on  a  piece  of 
paper  before  the  operation  commences.  The  swab  nurse 
will  also  hand  out  the  sterilized  towels,  dressings,  gauze, 
etc.,  as  the  surgeon  requires  them. 

General  nurse. — The  general  nurse  will  be  required 
to  fetch  and  carry  porringers  and  boxes  with  sterilized 
towels  and  dressings  therein,  to  prepare  antiseptic  solutions, 
get  ready  saline  infusions,  sterilize  any  additional  instru- 
ments that  may  be  required,  and  generally  to  make  herself 
useful,  but,  of  course,  from  the  very  nature  of  her  duties 
she  cannot  keep  her  hands  absolutely  aseptic  ;  she  will 
not  need,  therefore,  to  wear  gloves,  nor  will  she  require 
a  mask,  but  she  must,  of  course,  be  dressed  in  a  sterilized 
overall,  will  initially  prepare  her  hands  as  carefully  as 
the  rest  of  the  staff,  and  must  wash  them  subsequently 
as  often  as  occasion  requires  and  opportunity  offers. 

Health  and  cleanliness  of  the  operator  and  staff. — 
It  goes  without  saying  that  all  concerned  in  the  perform- 
ance of  an  operation  should  be  in  good  health,  and  should 
not  be  suffering  from  any  septic  condition  such  as  sore 
throat,  nasal  disease,  septic  wounds  on  the  fingers,  etc., 
and  if  any  one  of  them  has  been  in  contact  with  a  septic 
case  previous  to  the  operation,  he  or  she  should  have  had 
a  hot  bath  and  an  entire  change  of  raiment  just  before 
coming  to  the  operation.  With  the  advance  of  education 
and  the  better  understanding  of  the  principles  of  hygiene 


62  GYNECOLOGICAL  SURGERY 

by  the  general  community,  it  seems  superfluous  to  remark 
that  everyone  should  take  a  daily  bath  and  wear  clean 
clothes.  The  teeth  of  surgeons  and  nurses  should  be  kept 
in  perfect  order.  The  inferior  results  of  some  operators 
may  be  in  part  due  to  the  septic  condition  of  their  mouths. 

The  hair  of  the  operator  and  of  his  assistants  should  not 
be  unduly  long,  and  the  nurses'  hair  should  be  kept  well 
brushed  and  cleaned.  The  surgeon  has  little  control 
over  the  toilet  of  a  nurse,  but  at  any  rate  he  need  not 
employ  an  untidy  woman.  Doctors  and  nurses  should, 
of  course,  be  most  particular  in  keeping  their  nails  clean. 
One  has  seen  an  operator  commence  the  preparation  of 
his  hands  by  a  vigorous  cleaning  of  dirty  nails  with  nail- 
scissors,  scrubbing  brush,  etc.,  when  the  nails  to  commence 
with  should  have  been  reasonably  clean. 

Lastly,  one  who  is  constantly  operating  should  avoid 
touching  pus  or  any  other  septic  material  as  much  as 
possible.  It  is  better  to  keep  the  hands  free  of  septic  bac- 
teria than  to  rely  upon  destroying  them  afterwards  by 
washing  and  antiseptics. 

COSTUME    OF    OPERATOR    AND    STAFF 

Overalls. — Overalls  should  be  made  of  thin  linen, 
should  fasten  up  at  the  back,  and  should  have  sleeves 
down  to  the  wrist.  It  is  not  uncommon  to  see  a  surgeon, 
having  taken  the  greatest  care  about  the  preparation  of 
his  hands,  and  covered  them  before  the  operation  with 
sterilized  rubber  gloves,  put  on  an  overall  the  sleeves 
of  which  end  well  above  the  elbow,  so  that  a  large  portion 
of  his  arm  is  bare.  Instruments  and  ligatures  may  quite 
easily  touch  the  bare  arm,  and  we  have  seen  operators 
examining  the  stomach,  spleen,  kidneys,  and  other  ab- 
dominal organs  with  a  large  portion  of  the  bare  unsterilized 
arm  in  contact  with  the  abdominal  viscera. 

The  operator  can,  if  he  likes,  wear  a  mackintosh  under 
the  overall.  This  will  not  add  to  his  comfort,  and  in  the 
majority  of  cases  is  unnecessary,   but  in  septic  cases,   or 


OPERATING   COSTUME  63 

where  a  large  quantity  of  fluid  may  be  expected  to  be 
evacuated,  it  should  be  worn. 

Masks  (Fig.  38a). — Masks  should  be  worn  by  the  surgeon, 
his  assistant,  and  the  swab  and  instrument  nurses.  Masks 
have  various  uses  :  (1)  they  soak  up  any  perspiration,  which 
is  a  more  satisfactory  way  of  dealing  with  this  excretory 
product  than  allowing  it 
to  fall  into  the  peritoneal 
cavity  ;  (2)  if  made  after 
the  pattern  devised  by 
us,  they  will  keep  loose 
pieces  of  hair  and  dan- 
druff from  falling  about 
the  operation  area  ;  (3) 
most  important  of  all, 
they  prevent  saliva  from 
being  projected  into  the 
wound,  for  if  it  carries 
with  it  septic  debris  from 
decayed  teeth,  or  bacteria 
from  an  unhealthy  throat, 
the  results  may  be  dis- 
astrous to  the  patient. 
That  such  a  danger  is  not 

fanciful    we    have   proved  F.     M       A         .   _,         , 

f  r  lg.  3&7. — Operating  mask. 

by  going  through  dummy 

operations  over  "  culture  plates  "  in  the  place  of  patients, 
and  giving  such  directions  and  holding  such  converse  as 
would  be  necessary  in  a  real  operation.  These  plates,  com- 
pared with  controls  exposed  for  an  equal  length  of  time, 
showed  a  definitely  larger  number  of  colonies  on  incubation. 

Gloves. — India-rubber  gloves  which  have  been  boiled 
and  placed  in  biniodide  of  mercury,  1 — 1,000,  or  sterilized 
water,  according  to  the  wish  of  the  operator,  until  they 
are  required,  should  be  worn  by  the  surgeon  and  nurses 
for  all  operations. 

We  cannot  conceive  the  least  objection  to  their  use  ; 


64  GYNAECOLOGICAL  SURGERY 

they  can  be  absolutely  sterilized,  the  hands  cannot ;  and 
this  alone,  one  would  have  thought,  should  have  been 
sufficient  to  ensure  their  universal  use.  There  are  still  a 
few  operators,  however,  who  decline  to  use  them,  and  they 
point  with  pride  to  the  fact  that  their  death-rate  is  no 
higher  than  that  of  their  colleagues  who  use  gloves.  But 
if  these  operators  would  only  wear  sterilized  gloves  their 
death-rate  would  be  lower,  unless  their  experience  differed 
from  that  of  everyone  else  who  has  taken  to  wearing  gloves. 

Apart  from  the  question  of  mortality,  the  use  of  sterilized 
gloves  lowers  the  percentage  morbidity  in  a  marked  fashion, 
and  such  complications  as  stitch-abscesses,  etc.,  are  now 
very  rare  with  surgeons  who  wear  gloves.  Gloves  are 
objected  to  on  the  score  that  they  make  more  troublesome 
certain  operations  markedly  requiring  the  sense  of  tissue- 
appreciation,  such  as  difficult  cases  of  diseased  appendages 
with  adhesions  to  the  bowel ;  but  this  is  purely  a  matter 
of  practice,  and  if  a  surgeon  will  always  wear  gloves,  no 
matter  what  operation  he  is  doing,  he  will  find  this  difficulty 
soon  disappear. 

Again,  it  has  been  argued  that  gloves  are  dangerous 
because  if  they  are  pricked  or  torn  the  bacteria  which 
have  been  herded  up  inside  will  escape.  This  possibility 
is  avoided  by  filling  the  gloves  with  mercurial  solution 
before  putting  them  on,  when  a  certain  amount  will  remain, 
and  the  hand  will  be  kept  bathed  in  it. 

Finally,  it  is  most  important  to  remember  that  gloves 
not  only  prevent  the  operator's  hands  from  infecting  the 
patient,  but  also  prevent  the  patient  from  infecting  the 
operator's  hands  with  any  pus  that  may  be  present,  so  that 
the  hands  of  a  surgeon  who  habitually  uses  them  are  never 
exposed  to  the  risk  of  severe  infection. 

We  think  that  everyone  in  active  surgical  practice  should 
adopt  the  use  of  india-rubber  gloves  not  only  for  operative 
purposes  but  habitually  when  engaged  in  seeing  out- 
patients, going  round  his  wards,  or  examining  patients  in 
private  practice. 


CHAPTER    IV 

OPERATIONS  IN  PRIVATE  HOUSES 

Where  an  operation  is  to  be  performed  in  a  private  house, 
the  whole  responsibility  for  the  details  concerned  in  it 
rests  on  the  surgeon,  and  it  will  be  necessary  for  him  not 
only  to  prepare  his  own  outfit  but  to  give  minute  directions 
to  the  nurse  in  charge  as  to  all  arrangements  required  for 
its  performance. 

THE  SURGEON'S  OUTFIT 

Although  the  instruments  required  for  any  given  opera- 
tion are,  of  course,  the  same  whether  it  is  to  be  performed 
in  a  hospital  or  at  the  patient's  home,  it  is  advisable  in  the 
latter  case  to  carry  sufficient  additional  ones,  so  that  in 
the  event  of  the  operation  turning  out  to  be  of  a  different 
nature  from  the  one  anticipated,  the  surgeon  may  not  find 
himself  embarrassed  at  the  last  moment  by  want  of  the 
proper  tools. 

These  additional  instruments  need  not  be  sterilized, 
but  should  be  carried  in  the  bag  in  case  they  should 
be  required. 

Thus,  when  performing  a  minor  operation,  sufficient 
pressure-forceps,  ligature  material,  and  a  scalpel  should 
always  be  at  hand,  lest  it  be  necessary  to  open  the  abdomen. 
Similarly  a  pair  of  bowel-clamps  should  always  be  carried 
in  case  a  portion  of  the  intestine  should  have  to  be 
resected. 

The  methods  of  sterilizing  the  instruments  and  the 
rest  of  the  surgeon's  outfit  for  work  in  private  houses 
and  little-known  nursing-homes,  and  the  best  means  of 
their  transport,  will  be  found  fully  described  elsewhere 
(pp.  29-31). 

f  65 


66  GYNECOLOGICAL   SURGERY 

THE    NURSE'S    DUTIES 

The  duties  of  the  nurse  will  be  indicated  under  the 
following  heads  : — 

Preparation  of  the  room. — A  well-lighted  and  well- 
ventilated  room  on  the  first  floor  should  be  chosen,  and 
one  not  situated  near  a  water-closet.  All  superfluous 
furniture,  together  with  the  carpet,  curtains,  and  pictures, 
should  be  removed.  The  day  before  the  operation  the 
walls  should  be  well  dusted,  and  all  the  woodwork,  includ- 
ing the  tops  of  the  doors  and  windows,  washed  or  dusted 
with  damp  dusters.  The  furniture  also  should  be  dusted, 
and  the  floor  thoroughly  washed  with  soap  and  water,  and, 
when  dried,  well  swabbed  with  clean  water,  after  which  it 
should  be  scrubbed  with  perchloride  of  mercury,  i — 1,000. 

On  the  morning  of  the  operation  the  woodwork  and 
furniture  should  again  be  dusted  with  a  damp  duster. 
If,  however,  there  is  insufficient  time  for  this  preparation, 
owing  to  the  urgency  of  the  operation,  it  is  better  not  to 
disturb  the  dust,  but  simply  to  push  the  furniture  gently 
on  one  side,  and  place  a  sheet  soaked  in  perchloride  of 
mercury,  i — 1,000,  over  the  carpet  beneath  the  operating 
table. 

Bed. — If  possible,  a  single  iron  bedstead  with  a  spring  and 
horsehair  mattress  should  be  procured.  The  bed  should 
be  dusted  with  a  damp  duster,  should  not  have  any  valance, 
the  mattress  should  be  well  aired,  and  the  bed  made  as 
follows,  from  below  upwards  :  A  blanket,  lower  sheet, 
mackintosh  sheeting,  draw-sheet,  upper  sheet,  blanket. 
Just  before  the  operation,  two  or  three  hot-water  bottles 
should  be  placed  in  the  bed.  After  the  operation  is  over, 
and  just  before  the  patient  is  returned  to  bed,  these  bottles 
must  be  taken  out  of  the  bed,  and  if  the  operation  has  been 
of  such  a  nature  as  to  necessitate  their  further  use,  they 
must  be  applied  outside  the  blanket. 

Operation  table. — Every  operating  surgeon  should  have 
his  own  portable  table.     Most  of  those  on  the  market  are 


OPERATIONS  IN  PRIVATE  HOUSES        67 

designed  for  general  surgical  purposes  and  give  an  un- 
satisfactory Trendelenburg  tilt.  The  table  that  one  of  us 
has  designed  will  be  found  in  this  respect  simple  in 
mechanism  and  light  to  carry  (Fig.  30).  It  should  have 
on  it  one  blanket,  a  piece  of  mackintosh,  and  a  sheet. 
In  the  absence  of  some  such  table  the  best  substitute  is 
a  narrow  kitchen-table,  which  if  the  Trendelenburg  posture 
is  required  may  be  tilted  on  blocks,  or  the  patient's  buttocks 
may  be  elevated  by  bolsters  lashed  on  in  the  shape  of  a 
wedge. 

Instrument  tables,  etc. — Four  small  tables  will  be  re- 
quired :  one  for  the  anaesthetist's  apparatus,  one  for  the 
instruments,  one  for  a  basin  of  biniodide  of  mercury, 
1 — 1,000,  for  the  hands  (if  the  instrument  table  is  large 
enough,  this  can  be  placed  upon  it),  while  the  fourth  will 
be  needed  for  the  basins  to  hold  the  swabs.  If  suitable 
tables  cannot  be  procured,  an  ironing  board,  or  leaves  of 
an  extension  table  resting  on  chairs,  will  answer  the  purpose. 
The  tables  should  be  well  dusted  and  covered  with  clean 
towels  wrung  out  of  biniodide  of  mercury  solution,  1 — 1,000. 

Washstand. — On  this  should  stand  three  basins  :  one 
for  washing  the  hands  with  soap  and  water,  one  containing 
clear  water  to  rinse  the  soap  off,  and  one  containing  a 
solution  of  biniodide  of  mercury,  1 — 1,000,  for  completing 
the  preparation  of  the  hands.  In  this  the  india-rubber 
gloves  may  be  left  till  they  are  wanted. 

Chairs. — Two  chairs  are  required  :  one  for  the  anaes- 
thetist, and  one  (in  the  case  of  vaginal  operations)  for  the 
operator.  If  the  operation  necessitates  the  Trendelenburg 
position,  it  would  be  better  to  have  a  stool  or  a  low  chair 
for  the  anaesthetist  to  sit  on. 

Pail  or  foot-bath. — This  should  be  properly  cleansed, 
and  is  necessary  for  the  reception  of  any  soiled  water, 
whilst  in  vaginal  operations  it  is  necessary  to  have  such 
a  receptacle  for  the  douche  to  flow  into  on  leaving  the 
vagina. 

Linen. — Besides  the  sheets  already  mentioned,  a  number 


68  GYNECOLOGICAL  SURGERY 

of  old  towels  will  be  needed  :  a  dozen  will  be  sufficient  for 
any  case.  They  should  not  be  new  for  the  obvious  reason 
that  new  towels  soak  up  fluid  very  badly. 

Temperature  of  room. — The  temperature  of  the  room 
should  be  between  70  °  and  75  °  F. 

Accessaries. — -The  nurse  must  provide  the  following 
accessaries  : — 

A  nail-brush  that  has  been  sterilized  by  boiling. 

A  cake  of  soap,  germicidal  if  possible. 

A  bottle  of  brandy. 

A  long  rubber  rectal  tube. 

A  large-sized  soft  rubber  catheter  with  a  glass  fun- 
nel attached  for  administering  saline  or  brandy 
enemata. 

A  bath  thermometer  to  test  the  heat  of  solutions. 

Some  table  salt,  in  case  the  surgeon  wishes  to  give  a 
saline  injection. 

Though  not  a  necessity,  a  bed-cradle  to  keep  the 
clothes  off  the  patient  is  usefully  added  to  this 
list. 

If  the  nurse  is  unable  to  obtain  a  proper  bed-cradle, 
an  efficient  substitute  can  be  made  with  two  wooden  hoops 
as  used  by  children,  cutting  them  in  halves  and  joining  the 
four  curved  pieces  by  three  straight  pieces  of  wood  2  in. 
broad. 

Water. — Three  gallons  of  cold  water  which  has  been 
boiled  must  be  provided,  and  three  gallons  of  water  must 
be  boiled  just  before  the  operation.  Pieces  of  gauze  should 
be  tied  over  the  top  of  the  jugs  ;  and  provision  should  be 
made  for  a  further  supply  of  water  in  case  it  should  be 
needed. 

It  is  customary  for  the  surgeon  to  bring  his  instru- 
ments, ligatures,  gloves,  dressings,  aprons,  masks,  towels, 
and  swabs  already  sterilized,  but  if  he  elects  not  to  do  so 
the  nurse  will  have  to  sterilize  them  for  him  as  follows  : — 

Instruments. — A  kettle  or  saucepan,  preferably    a   fish- 


OPERATIONS  IN  PRIVATE  HOUSES        69 

kettle,  is  three  parts  filled  with  water  and  a  piece  of  washing 
soda  the  size  of  a  cob-nut  is  added  ;  this  will  prevent  the 
instruments  from  rusting.  The  instruments,  excepting  the 
scalpel,  are  then  boiled  for  half  an  hour.  As  the  edge  of 
the  scalpel  is  dulled  by  boiling,  some  other  method  of  steril- 
ization is  preferable,  such  as  putting  it  in  absolute  alcohol 
or  carbolic  acid,  1 — 20,  for  two  hours  before  the  operation. 

The  needles  should  be  stuck  in  a  piece  of  lint  before 
they  are  boiled. 

Dishes,  etc. — A  large  dish  for  instruments,  say  14  in. 
square,  and  a  smaller  dish  8  in.  square  for  sutures,  ligatures, 
and  needles.  In  the  absence  of  surgical  dishes,  meat  dishes 
will  suffice.  For  a  major  operation,  two  wash  basins  will 
be  required  for  the  swabs ;  for  a  minor  operation,  two  large 
pudding  basins,  one  for  the  clean  and  one  for  the  dirty 
swabs.  These  dishes  should  be  boiled  if  possible,  or  at 
any  rate  scalded,  before  use,  and  then,  having  been  turned 
upside  down  on  a  sterilized  cloth  to  keep  out  all  dust, 
should  be  covered  with  towels  until  required. 

A  pint  measure  will  be  required  for  mixing  the  anti- 
septic solutions,  and  also  bowls  for  solutions. 

Ligatures. — Silk,  thread,  and  silkworm-gut  should  be 
boiled  for  an  hour.  The  sterilization  of  catgut  is  beyond 
the  province  of  the  nurse,  in  private  work  at  least. 

Gloves. — The  gloves  are  sterilized  by  boiling  for  half 
an  hour.  The  nurse  must  not  forget  to  wet  them  inside 
beforehand.  They  should  be  boiled  separately  from  the 
instruments  if  possible,  so  that  they  may  not  be  holed. 
When  sterilized  they  should  be  transferred  to  a  large  bowl 
of   antiseptic   solution. 

Overalls. — It  is  impossible  to  sterilize  overalls  in  a 
private  house.  If  the  surgeon,  therefore,  does  not  bring 
his  own,  they  had  better  be  dispensed  with,  and  towels  used 
instead  to  swathe  the  operator  and  his  assistant. 

Towels. — The  towels  for  surrounding  the  operation- 
area  should  be  sterilized  by  boiling  and  afterward  trans- 
ferred to  a  1 — 1,000  biniodide  of  mercury  solution.     When 


70  GYNAECOLOGICAL  SURGERY 

required  for  use  they  must  be  wrung  out.  As  they  must 
of  necessity  be  used  wet,  between  them  and  the  patient 
pieces  of  waterproof  batiste  should  be  placed.  A  similar 
arrangement  will  be  needed  if  they  are  used  instead  of 
overalls  for  the  surgeon  and  his  assistant. 

Swabs.- — If  the  surgeon  leaves  the  nurse  to  prepare 
the  swabs,  these  should  be  sterilized  by  boiling  for  one 
hour,  and  afterwards  transferred  to  a  i — 1,000  solution  of 
biniodide  of  mercury.  They  must  be  wrung  out  in  plain 
sterilized  water  before  use. 


CHAPTER    V 

EXAMINATION    AND    PREPARATION    OF    THE 
PATIENT 

I.    BEFORE  THE  OPERATION 

All  patients  before  being  subjected  to  any  operative 
procedure  should  undergo  a  certain  amount  of  preparation 
at  the  hands  both  of  the  surgeon  and  of  the  nurse,  and  it 
is  only  in  operations  of  a  very  urgent  nature,  as,  for  instance, 
a  ruptured  tubal  gestation  associated  with  an  alarming 
internal  haemorrhage,  that  this  preparation  should  be 
dispensed  with.  The  amount  of  preparation  necessary 
depends  upon  whether  the  operation  is  of  a  major  or  minor 
kind,  and  on  the  state  of  health  of  the  patient. 

Examination  of  the  Patient 

Before  any  patient  is  subjected  to  an  operation  it  is 
the  duty  of  the  surgeon  to  acquaint  himself  by  personal 
examination  with  the  general  condition  of  her  health. 
For  this  purpose  he  should  make  an  examination  of  her 
heart,  lungs,  and  kidneys,  since  their  condition  may  have 
an  important  bearing  upon  the  result  of  the  operation. 
It  is  quite  obvious  that  if  the  patient  is  suffering  from 
some  serious  or  fatal  disease  an  operation  on  the  score  of 
expediency  is  contra-indicated,  and  one  should  only  be 
performed  when  absolutely  necessary  to  save  life  or  for 
the  relief,  perhaps  only  temporary,  of  some  distressing 
local  condition. 

In  cases  where  the  patient's  life  is  not  in  immediate 
danger  it  may  be  wiser  to  postpone  operative  measures 
until  she  is  better  able  to  stand  them  and  there  is  less 
risk.     For  instance,  women  who  have  been  flooding  from 

7i 


72  GYNECOLOGICAL  SURGERY 

fibrosis  of  the  uterus  are  bad  subjects  for  operation.  The 
heart  is  flabby  and  weak,  and  in  danger  of  failing  under 
the  stress  of  a  severe  operation,  and  the  profound  anaemia 
predisposes  to  femoral  or  other  thrombosis  with  all  its 
attendant  risks  and  discomforts  after  the  operation.  These 
patients  should  not  be  operated  upon  until  the  next  period 
is  nearly  due,  and  in  the  meantime  measures  should  be 
taken  to  improve  the  general  health.  In  cases  of  acute 
pyo-salpinx,  unless  the  patient  has  general  peritonitis  we 
have  found  it  much  safer  to  wait  till  the  acute  attack  has 
passed  off  and  the  temperature  is  approaching  the  normal, 
by  which  time  the  opsonic  index  of  the  patient  is  such  that 
she  is  able  to  deal  with  any  pus  that  is  let  loose  during 
the  operation. 

It  must  also  be  remembered  that  the  anaesthetist's 
choice  of  the  anaesthetic  is  influenced  by  the  report  given 
to  him  of  her  general  health. 

The  shock  following  a  major  operation  is,  of  course, 
much  more  severe  than  that  after  one  of  a  minor  character, 
and  is  sometimes  the  direct  cause  of  death.  It  may  there- 
fore be  that  whereas  the  general  condition  of  the  patient 
would  not  contra-indicate  a  slight  operation,  one  of  a 
serious  nature  would  be  highly  dangerous.  After  a  long 
and  severe  operation,  perhaps  accompanied  by  a  serious 
loss  of  blood,  the  heart  may  fail,  and  great  difficulty  is 
experienced  in  restoring  its  balance.  Four  days  prior  to 
any  major  operation  a  hypodermic  injection  of  liq.  strych- 
ninae  rr\iii  is  with  advantage  given  twice  daily,  or  the 
same  amount  in  a  mixture  three  times  daily.  This  lessens 
the  danger  of  postoperative  shock,  and  is  said  to  keep 
the  intestines  well  contracted  and  so  render  them  less 
liable  to  become  distended  after  the  operation. 

In  hospital  practice  it  falls  to  the  lot  of  a  surgeon  to 
have  to  operate  upon  many  patients  who  are  debilitated 
by  a  life  of  constant  hard  work  and  hardship  amidst 
insanitary  surroundings,  and  who  have  been  in  daily 
want  of   sufficient   and  wholesome    food.     Many    of   them 


PREOPERATIVE   EXAMINATION  73 

have,  in  addition,  still  further  diminished  their  resist- 
ing power  by  drink.  Where  a  major  operation  is  con- 
templated on  a  patient  such  as  this,  it  is  advisable  to 
keep  her  at  rest  and  feed  her  up  for  at  least  a  week 
beforehand. 

Cardiac  disease. — Heart  disease  is  not  necessarily  a 
contra-indication  to  operative  measures,  although,  of 
course,  these  cases  assume  a  more  serious  aspect,  since 
shock  itself  is  a  powerful  depressant  of  the  heart.  As 
chloroform  may  not  be  a  safe  drug  to  administer  to  a 
patient  suffering  from  some  forms  of  cardiac  disease,  it 
will  be  the  surgeon's  duty  to  inform  the  anaesthetist 
of  this  complication,  should  it  be  present,  before  the 
anaesthetic  is  administered.  Patients  with  compensated 
valvular  disease  stand  all  ordinary  operative  procedures 
as  well  as  healthy  persons,  but  where  compensation  is 
failing,  no  operation  should  be  undertaken,  except  of  urgent 
necessity.  From  the  surgeon's  point  of  view,  fatty  degenera- 
tion of  the  cardiac  muscle  is  the  gravest  of  all  heart  lesions, 
and  the  more  so  because  its  presence  is  with  difficulty 
diagnosed  before  the  operation.  The  most  valuable  indica- 
tion of  cardiac  degeneration  is  the  detection  of  sclerotic 
changes  in  the  accessible  arteries.  On  this  account  the 
surgeon  should  never  forget  to  examine  the  radial  artery 
at  the  wrist  and  the  brachial  artery  at  the  bend  of  the 
elbow.  A  tortuous  condition  of  these  vessels,  especially 
when  combined  with  an  alcoholic  history,  is  an  almost 
sure  sign  of  a  heart  enfeebled  by  fatty  degeneration.  These 
patients  bear  severe  operations  exceedingly  badly,  the 
rapid  heart-action  thereby  induced  leading  not  infrequently 
to  acute  dilatation,  which  often  proves  fatal  in  a  few  days. 
At  the  present  day  post-mortem  findings  show  that  this 
condition  accounts  for  more  deaths  after  major  operations 
than  does  any  other  cause. 

Pulmonary  disease. — As  will  be  seen  later  on,  ether 
has  a  tendency  in  some  cases  to  cause  bronchitis  or  broncho- 
pneumonia.     If,    therefore,    on   examination   of   the   lungs, 


74  GYNAECOLOGICAL  SURGERY 

the  surgeon  should  detect  any  signs  of  bronchitis,  he  would 
be  wise  to  postpone  the  operation  until  these  have  cleared 
up.  If  the  operation  is  imperative,  chloroform  must  be 
used,  not  ether,  or  spinal  anaesthesia  must  be  employed. 
Patients  suffering  from  pulmonary  tuberculosis  take  anaes- 
thetics badly,  and  run  a  danger  of  an  acute  exacerbation 
of  the  disease. 

Renal  disease  and  diabetes. — The  urine  of  the  patient 
should  always  be  carefully  examined  for  albumin,  blood, 
sugar,  and  pus  before  an  operation  is  undertaken,  and 
the  quantity  passed  in  the  twenty-four  hours  should  be 
measured.  No  patient  with  diabetes  should  be  subjected 
to  an  operation  unless  it  be  one  of  an  urgent  nature  to 
save  life.  If  it  is  very  important  that  an  operation  be 
performed,  and  there  is  time,  the  diabetes  must  be  treated 
by  careful  dieting  and  codeia,  commencing  with  half  a  grain 
three  times  daily  and  increasing  the  dose  to  as  much  as  six 
or  eight  grains  in  the  twenty-four  hours  ;  when  the  amount 
of  sugar  excreted  has  been  lessened  the  operation  may  be 
undertaken  with  more  chance  of  success.  We  have  operated 
successfully  upon  patients  with  advanced  diabetes.  The 
two  great  risks  that  confront  the  surgeon  are  coma  and 
gangrene,  both  of  which  appear  to  depend  upon  the  presence 
in  the  blood  of  /3-oxybutyric  acid  and  diacetic  acid.  The 
risk  of  coma  and  gangrene  may  be  minimized  by  the 
exhibition  of  large  doses  of  carbonate  of  soda  for  some 
days  beforehand ;  and  at  the  operation,  acting  under 
Dr.  Pavy's  advice,  we  have  injected,  intravenously,  a  car- 
bonate-of-soda  solution  containing  two  drachms  of  this 
drug  to  two  pints  of  sterilized  water.  In  cases  of  post- 
operative diabetic  gangrene  we  have  seen  remarkable  im- 
provement rapidly  follow  the  administration  of  large  doses 
of  bicarbonate  of  soda  by  the  mouth.  Again,  if  albumin 
is  detected  in  the  urine,  the  patient  should,  if  possible,  be 
treated  until  the  amount  has  considerably  diminished  or 
disappeared.  Patients  with  renal  disease  do  not  stand 
operative    measures    very    well.      Ether    is    an    unsuitable 


PREOPERATIVE   EXAMINATION  75 

anaesthetic  for  those  suffering  from  Bright 's  disease,  and 
chloroform  when  diabetes  is  present. 

Thyroid  tumours. — Patients  with  simple  goitres,  as 
long  as  these  are  not  interfering  with  respiration,  bear 
operations  as  well  as  other  people  ;  but  where  symptoms 
of  Graves'  disease  are  present  the  case  is  very  different. 
Such  patients  take  the  anaesthetic  very  badly,  and  there 
is  a  liability  to  sudden  death  during  the  operation,  or  un- 
controllable heart  hurry  and  failure  in  the  days  immediately 
succeeding  it. 

Insanity. — We  have  performed  operations,  both  major 
and  minor,  upon  insane  patients,  and  have  not  found  that 
the  convalescence  or  the  mental  condition  was  materially 
affected  one  way  or  the  other  as  a  result.  Of  course,  no 
surgeon  should  undertake  an  operation  upon  an  insane 
person,  except  in  great  urgency,  unless  he  has  been  advised 
by  a  mental  specialist  that  the  result  of  the  operation  would 
be  beneficial  to  her. 

Besides  patients  actually  insane,  there  are  those  whose 
mental  stability  is  trembling  in  the  balance,  and  in  these 
more  than  in  any  others  it  is  proper,  both  for  the  good  of 
the  patient  and  for  the  protection  of  the  surgeon,  to  take 
the  advice  of  a  mental  specialist  before  performing  an 
operation. 

Pregnancy. — If  during  the  routine  examination  of  his 
patient  before  operation  the  surgeon  should  discover 
that  she  is  pregnant,  he  will  decide  not  to  operate, 
except  in  cases  of  real  necessity,  because  of  the  liability, 
especially  in  some  women,  to  miscarry  even  after  slight 
operations. 

Directions  to  the  Nurse 
It  is,  of  course,  a  matter  of  prime  necessity  that  the 
nurse  or  nurses  should  have  been  thoroughly  trained  and 
have  an  adequate  knowledge  of  asepsis  and  antisepsis, 
and  how  to  prepare  themselves  and  the  patient  for  opera- 
tion.     In  hospitals   and  good  nursing-homes   the  surgeon 


76  GYN/ECOLOGICAL  SURGERY 

should  lay  down  a  routine  to  be  followed  in  all  cases,  and 
for  its  execution  the  ward  and  theatre  sisters  are  to  be 
held  responsible.  In  a  well-organized  institution,  possessed 
of  the  services  of  highly-trained  and  intelligent  women, 
much  responsibility  is  thus  removed  from  the  shoulders  of 
the  operator,  but  it  still  behoves  him  to  exercise  a  general 
supervision  over  the  ward  and  theatre  work,  and,  without 
harshness,  to  insist  that  it  be  properly  performed.  If  the 
operation  is  to  take  place  at  the  patient's  house  the  surgeon 
cannot  delegate  his  responsibility  in  this  manner,  and  he 
should  therefore  be  careful  to  choose  capable  nurses  and 
to  give  them  minute  directions  for  preparing  the  patient, 
preparing  the  operating  room,  and  sterilizing  the  instru- 
ments and  dressings  (if  he  does  not  do  this  himself).  To 
one  who  is  frequently  operating,  it  will  be  found  both 
convenient  and  a  great  saving  of  time  if  he  has  his  directions 
printed,  so  that  the  nurse  can  be  given  a  set.  Unless  this 
is  done,  the  nurse  cannot  be  held  responsible  if  anything 
is  forgotten. 

Communications  to  the  Patient  and  her  Friends 

If  the  patient  is  a  married  woman,  her  husband  should 
be  informed  of  the  exact  nature  of  the  operation,  together 
with  its  probable  results  and  risks,  as  estimated  from  the 
practice  of  experienced  surgeons.  If  she  be  single,  then 
her  mother  or  nearest  living  relative  should  be  informed 
of   these   details. 

Exactly  how  much  should  be  told  the  patient  is  a 
more  difficult  matter  to  decide.  Of  course,  the  patient 
has  every  right  to  know  the  worst  as  well  as  the  best,  and 
if  she  requests  to  be  informed  of  the  exact  degree  of 
danger  as  far  as  experience  shows,  she  should  be  told.  The 
only  way  in  which  this  can  be  conveyed  to  her  is  by  telling 
her  of  the  death-rate  in  similar  cases  with  skilled  operators 
under  favourable  conditions ;  and  this  should  be  done. 
As  a  rule,  the  patients  themselves  are  not  so  inquisitive 
as  this,  and  the  most  they  will  ask  is  whether  the  operation 


PREOPERATIVE   EXAMINATION  77 

is  dangerous  or  not,  the  answer  to  which  will  depend  on 
the  nature  of  the  operation.  With  major  operations  the 
patient  must  be  told,  if  she  asks,  that  there  is  an  element 
of  danger,  but,  if  the  condition  warrants  such  a  statement, 
that  this  is  only  slight,  and  certainly  nothing  approaching 
to  that  which  she  must  run  if  the  disease  is  left  untreated. 

In  a  few  cases,  but  only  a  very  few,  when  an  operation 
is  necessary  to  save  life  and  when  the  patient  is  so  nervous 
that  the  truth  as  to  the  danger  involved  might  ensure 
her  refusal  to  submit  to  it,  the  gravity  of  the  operation 
may  be  somewhat  minimized,  with  the  consent  of  the 
husband  or  nearest  relatives,  after  they  have  been  put  in 
full  possession  of  all  the  facts.  If  the  operation  is  of  such 
a  nature  that  the  ovaries  or  uterus  will  have  to  be  removed, 
the  patient  and  her  husband  if  she  be  married,  or  the  patient 
and  her  parents  if  she  be  single,  must  be  made  thoroughly 
to  understand  that  the  results  will  be  sterility  and  the 
menopause. 

Lastly,  the  surgeon  will  be  wise  if,  before  he  performs 
a  major  operation  on  a  patient  which  will  probably  neces- 
sitate the  removal  of  the  ovaries  or  uterus,  he  obtains  from 
her  a  letter,  signed  and  witnessed,  giving  him  a  free  hand. 
This  is  now  a  rule  in  many  hospitals  for  all  patients,  and 
it  would  be  better  if  it  were  so  in  private  work.  The  neglect 
of  this  simple  precaution  has  caused  much  trouble  and 
anxiety  to  surgeons  in  the  past. 

In  rare  cases  a  patient  will  consent  to  the  removal 
of  one  ovary  or  one  tube,  but  not  of  both,  and  in  these 
circumstances  it  becomes  a  moot  point  whether  the  surgeon 
should  operate  or  not.  We  think  he  would  be  consulting 
his  own  interests  best,  and  also  those  of  the  patient,  if  he 
refused,  because  in  many  cases  there  is  no  means  of  knowing 
the  exact  condition  of  affairs  until  the  abdomen  is  opened, 
and  then  if  both  appendages  are  diseased  a  great  difficulty 
presents  itself.  If,  however,  a  surgeon  elects  to  operate 
under  such  restricted  conditions,  he  must  be  careful  not 
to  do  more  than  he  has  had  leave  to  do,  and  therefore  he 


7«  GYNECOLOGICAL  SURGERY 

should  not  interfere  at  all  with  any  other  diseased  structures, 
since  an  examination  of  them  might  start  such  serious 
haemorrhage  that  they  would  have  to  be  removed.  Of 
course,  if  these  restrictions  are  imposed,  the  patient  is 
entirely  responsible  for  the  results  of  the  operation,  should, 
say,  a  pyo-salpinx  or  an  ovarian  tumour  be  left  behind. 

When  from  experience  a  surgeon  knows  that  certain 
operations  are  not  always  successful,  such  as  curetting  for 
bleeding  in  endometritis,  dilatation  of  the  cervix  for 
dysmenorrhcea  or  sterility,  removal  of  a  urethral  caruncle, 
perineoplasty  for  prolapse,  etc.,  he  should  be  perfectly 
open  with  the  patient  and  tell  her  that  he  cannot  guarantee 
a  successful  issue,  but  that  in  a  large  number  of  cases  the 
operation  is  successful,  whilst  on  the  other  hand  there 
is  no  serious  danger  in  it  if  properly  performed.  The  patient 
will  fully  appreciate  this,  and  will  practically  in  all  cases 
consent  to  an  operation.  The  disappointment  of  a  patient 
who,  having  been  told  by  her  surgeon  that  some  operation 
will  cure  her,  discovers  that  she  is  very  little  or  no  better, 
is  naturally  great,  and  she  will  very  likely  lose  faith  in  that 
surgeon  and  turn  for  relief  to  someone  else. 

Preparation  of  the  Patient 

Report    on    the    pulse,    temperature,    and    urine. — In 

every  case  the  nurse  should  take  the  pulse  and  temperature 
morning  and  evening  before  the  operation  and  chart  it  ; 
she  should  also  measure  the  quantity  of  urine  passed  in 
the  twenty-four  hours  and  make  a  note  of  that. 

PREPARATION   OF   THE    PATIENT   FOR  MINOR   OPERATIONS 

Preoperative  rest  in  bed. — As  a  rule,  if  the  patient 
remains  in  bed  for  twenty-four  hours  before  the  operation 
this  will  be  sufficient.  In  certain  diseases,  when  the  parts 
require  some  days  to  render  them  aseptic,  the  patient 
need  not  be  kept  in  bed  all  the  time. 

Shaving  the  vulva. — Before  any  operation  on  the 
genital    organs,    the    vulva   should   be   shaved.     In   major 


PREOPERATIVE   PREPARATION  79 

operations  all  the  pubic  hair  must  be  removed,  but  in 
minor  operations  it  will  suffice  to  shave  that  on  the 
labia  majora  only.  The  instruments  required  are  scissors, 
razor,  shaving  brush,  and  mercurial  soap.  The  hair 
covering  the  vulva  should  at  first  be  cut  short  with 
scissors,  after  which  the  parts  should  be  well  lathered 
for  several  minutes  before  the  razor  is  used.  The  razor 
must  be  sharp,  and  should  be  dipped  for  a  second  into 
boiling  water  before  use. 

The  different  portions  of  the  labia  majora,  mons  veneris, 
and  perineum  are  rendered  taut  by  the  fingers  of  the  left 
hand,  whilst  with  the  razor  in  the  right  hand  the  hair  is 
removed  ;  the  accumulation  of  hair  and  soap  being  wiped 
from  the  razor  when  necessary  by  wool  swabs.  By  using 
a  safety  razor  all  creases  in  the  skin  can  be  closely  shaved 
even  by  one  inexperienced  in  this  art.  If  the  patient  is 
very  fat,  the  nurse  may  experience  some  difficulty  in 
shaving  the  necessary  area,  but  this  may  be  overcome 
by  propping  up  the  pelvis  with  a  pillow  underneath  the 
patient's  buttocks  or  by  first  placing  the  patient  in  the 
knee-elbow  position. 

Bath. — After  being  shaved,  the  patient  should  have  a 
hot  bath  consisting  of  10  gallons  of  water  at  a  temperature 
of  1050  F.,  to  which  has  been  added  five  pints  of  a  solution 
of  carbolic  acid,  1 — 20.  She  should  well  wash  her  body 
with  soap  and  water,  especial  attention  being  devoted  to 
the  locality  of  the  operation,  and  after  drying  she  should 
return  to  bed. 

Local  antisepsis. — The  patient  now  lies  on  her  back, 
with  her  nightgown  drawn  up  round  her  waist,  on  a  clean 
draw-sheet  with  mackintosh  underneath,  and  a  vaginal 
douche  is  given  of  biniodide  of  mercury  (t — 2,000),  2  quarts. 

The  vulva  and  parts  immediately  adjacent  are  rendered 
as  sterile  as  possible  by  the  nurse  scrubbing  them  with  ab- 
sorbent wool  dipped  in  ethereal  soap,  which  is  then  removed 
with  warm  water,  after  which  the  parts  are  finally  swabbed 
with    biniodide    of    mercury    (1 — 2,000),    and    a    compress 


8o  GYNAECOLOGICAL  SURGERY 

consisting  of  a  pad  of  Gamgee  tissue  wrung  out  of  biniodide 
of  mercury  (i — -2,000)  is  adjusted  over  the  vulva  and  kept 
in  position  by  a  sterilized  T-bandage. 

Douching. — -The  following  articles  are  required  :  A 
douche-can,  a  bidet,  a  bath  thermometer,  a  measure  and 
jug.  The  douche-can  should  hold  two  quarts  and  have 
6  ft.  of  tubing  attached  to  it.  Near  the  free  end  of  the 
tube  should  be  a  tap,  and  to  the  free  end  should  be  attached 
a  glass  nozzle. 

All  pillows  having  been  removed  to  tilt  the  pelvis,  the 
patient  is  placed  on  the  bidet,  the  douche-pan  is  raised  to 
a  height  of  about  6  ft.,  and  the  nozzle  of  the  douche  intro 
duced,  first  separating  the  labia.  Before  the  nozzle  is 
passed,  the  vulva  should  be  swabbed  with  biniodide  of 
mercury,  1 — 1,000. 

In  the  preparation  of  the  douche  the  nurse  should  be 
particularly  careful  to  ensure  that  it  is  of  the  strength 
ordered  and  of  the  proper  temperature,  for  by  neglecting  to 
take  these  precautions  she  may  seriously  injure  the  patient 
by  poisoning  or  scalding  her.  The  chemicals  to  be  used  in 
the  douche  should  always,  therefore,  be  first  measured  and 
then  mixed  with  the  water  in  a  jug,  and  the  temperature 
tested  with  a  bath  thermometer  before  the  solution  is 
poured  into   the   douche-can. 

The  douche-can,  bidet,  and  tubing  should  be  made 
aseptic  by  carefully  washing  and  scrubbing  them  with  soap 
and  water,  and  afterwards  with  carbolic  acid,  1 — 20,  while 
the  glass  nozzle  should  be  boiled  both  before  and  after 
its  use,  and  between  whiles  kept  in  a  solution  of  biniodide 
of  mercury,   1 — 1,000. 

When  giving  a  douche  for  antiseptic  purposes,  the  tem- 
perature of  the  solution  should  be  1050  F.  It  should  take  five 
minutes  for  two  quarts  of  douche  to  run  through.  If  the 
surgeon  wishes,  therefore,  for  a  more  prolonged  douching, 
arrangements  must  be  made  to  empty  the  bidet,  so  that 
a  pail  will  be  required  in  addition,  or  a  bidet  can  be  obtained 
with  an  outlet  to  which  rubber  tubing  is  affixed,  the  free 


PREOPERATIVE   PREPARATION  81 

end  being  dropped  in  the  pail ;  the  solution  will  then  run 
out  of  the  bidet  into  the  pail. 

Whenever  a  vaginal  operation  is  contemplated  the 
patient  should  be  instructed  to  douche  herself  twice  daily 
with  some  mild  antiseptic  for  a  week  beforehand. 

Bowels. — The  evening  but  one  before  the  operation  the 
patient  is  given  some  aperient  that  will  cause  the  bowels 
to  act  thoroughly.  It  does  not  signify  particularly  what 
aperient  is  given,  so  long  as  it  is  effective,  and  with  this 
knowledge  the  patient  may  choose  her  aperient.  In  the 
absence  of  any  particular  fancy,  she  may  take  the  following, 
which  will  be  found  most  efficient  : — 

B?     Mag.  sulph.  5ii. 
Sod.  sulph.  5L 
Ext.  glycyr.  gr.  xx. 
Olei  pimentae    iru. 
Ess.  menth.  pip.    irtv. 
Infus.  sennce  ad  §i. 

On  the  morning  of  the  operation  an  enema  composed 
of  two  pints  of  soap  and  water  is  injected,  after  the  action 
of  which  the  parts  are  thoroughly  cleansed,  as  before. 
If  the  operation  is  one  for  perineoplasty,  posterior  colpor- 
rhaphy,  recto- vaginal  fistula,  etc.,  to  guard  against  any 
faecal  matter  soiling  the  operation  area  it  is  found  best 
to  administer  an  enema  the  night  preceding  the  operation 
as  well  as  one  on  the  morning  of  the  operation. 

Where  the  patient  only  enters  the  hospital  or  nursing-home 
on  the  day  before  the  operation  an  ounce  of  castor  oil  should 
be  given  about  3  p.m.,  so  that  its  action  is  over  by  the  time 
the  patient  is  ready  to  go  to  sleep,  and  then  on  the  morning 
of  the  operation  an  enema  of  soap  and  water  is  administered 
about  three  hours  before.  After  the  enema  has  acted,  the 
parts  should  be  thoroughly  cleaned  up  again,  a  vaginal 
douche  given,  and  the  compress  re-applied. 

Bladder. — The  patient  should  pass  her  urine  just   before 
the  operation.     It  is  not,  as  a  rule,  necessary  to  use  the 
catheter. 
G 


82  GYNECOLOGICAL  SURGERY 

Dress. — The  patient  should  have  on  a  clean  night- 
gown, flannel  dressing  jacket,  and  a  pair  of  clean  flannel 
drawers,  or,  better  still,  long  -  woollen  stockings  reaching 
to  the  groins. 

The  hair  is  dressed  in  a  plait,  and  any  false  teeth  should 
be  removed  before  the  patient  gets  on  the  table. 

Food. — Up  to  the  day  of  the  operation  the  patient 
may  have  her  ordinary  diet,  supposing  it  to  be  a  judicious 
one,  and  at  6  a.m.  on  the  day  of  the  operation,  if  this 
is  to  take  place  at  2  p.m.,  she  is  given  a  cup  of  tea  and 
two  thin  slices  of  bread  and  butter.  At  10  a.m.  half  a  pint 
of  beef-tea  is  allowed,  and  nothing  further  until  after  the 
operation,  for  if  the  stomach  is  not  empty  during  the 
anaesthesia  the  patient  may  vomit  and  pieces  of  food  may 
be  inhaled  and  suffocation  result. 

PREPARATION    OF   THE    PATIENT    FOR  MAJOR   OPERATIONS 

Preoperative  rest  in  bed.  —  It  would  benefit  most 
patients  to  be  kept  in  bed  for  a  week  before  the  operation,  so 
that  the  nervous  and  vascular  systems  may  be  quieted  and 
the  intestinal  canal  cleared  of  any  accumulation.  This  is 
a  counsel  of  perfection,  and  many  patients  will  not  submit 
to  such  a  lengthy  preparation  ;  indeed,  in  certain  cases 
the  surgeon  will  only  be  able  to  obtain  the  patient's  consent 
if  he  operates  within  twenty-four  or  thirty-six  hours. 

Shaving. — The  nurse's  duties  in  this  respect  are  the 
same  as  are  set  out  for  operations  on  the  vagina.  It  is  most 
important  that  all  the  vulva  should  be  shaved  and  the 
vagina  thoroughly  douched  before  an  abdominal  section, 
since  it  is  sometimes  necessary  during  the  removal  of  an 
abdominal  tumour  to  employ  some  manipulation  per 
vaginam,  or  the  pelvic  cavity  may  have  to  be  drained  by 
this  route. 

Bath. — As  for  minor  operations.  In  individual  instances, 
on  account  of  the  serious  condition  of  the  patient,  a  bath 
may  not  be  possible,  in  which  case  the  surgeon  will  direct 
the  nurse  to  wash  her  in  bed. 


PREOPERATIVE  PREPARATION  83 

Local  antisepsis. — For  the  operations  of  vaginal  hys- 
terectomy and  colpotomy  the  local  antisepsis  is  the  same 
as  that  for  minor  operations. 

In  cases  of  abdominal  section  it  is  most  important  that 
the  field  of  operation  should  be  rendered  aseptic,  since 
not  only  will  the  risk  of  stitch-abscess  be  greatly  diminished, 
but  also  there  will  be  less  chance  of  the  surgeon  infecting 
his  patient  by  introducing  septic  organisms  from  the  skin 
into  the  peritoneal  cavity.  Having  returned  from  her 
bath,  the  patient  is  put  to  bed  and  her  nightdress  rolled 
up  to  her  chest,  the  bedclothes  covering  her  having  been 
previously  removed,  with  the  exception  of  a  blanket,  which 
is  turned  below  the  pubes.  On  account  of  the  exposure 
that  will  be  necessary  to  carry  out  the  following  directions, 
all  windows  and  doors  should  be  closed  and  the  tempera- 
ture of  the  room  should  not  fall  below  650  F.  Sterilized 
towels  having  been  placed  under  the  patient,  and  over  her 
chest  and  legs,  to  cover  the  nightgown  and  blanket  respec- 
tively, the  abdomen,  pubes,  and  sides  are  thoroughly 
washed  with  soap  and  water,  and  the  skin,  if  it  will  stand 
such  treatment,  is  scrubbed  with  a  sterilized  nail-brush. 
Particular  attention  should  be  devoted  to  the  umbilicus, 
especially  in  stout  patients,  in  whom  this  depression  may 
have  to  be  cleansed  with  wool  held  in  dressing  forceps. 
All  soap  having  been  removed  by  swabs  of  absorbent  wool, 
the  nurse  again  washes  her  hands,  after  which  she  rubs 
turpentine  well  into  the  operation  area.  After  removal 
of  the  turpentine  by  swabs,  ether  is  applied  to  the  same 
surface  until  the  swabs  used  with  this  fluid  are  no  longer 
discoloured.  Lockwood's  spirit  biniodide  solution  is  then 
rubbed  over  the  skin,  after  which  a  sterile  gauze  pad  is 
applied  until  the  operation. 

An  alternative  method  of  disinfecting  the  skin  is  by 
iodine.  It  can  be  used  in  acute  cases  where  there  is  no 
time  to  prepare  the  skin  as  already  described.  A  2  per 
cent,  solution  in  rectified  spirit  is  painted  over  the  abdomen 
on  the  morning  of  the  operation,  and  again  a  few  minutes 


«4  GYNAECOLOGICAL  SURGERY 

before  it  begins.  The  skin  must  be  perfectly  dry  or  the 
iodine  will  not  penetrate  deeply. 

In  urgent  cases,  therefore,  the  skin  must  not  be  washed 
and  the  pubic  hair  should  be  dry-shaved. 

Bowels. — The  patient's  bowels  are  kept  well  acting  by 
the  administration  of  an  aperient  every  day  if  necessary, 
and  the  final  preparation  is  similar  to  that  for  minor 
operations  (p.   81). 

Bladder. — When  any  major  operation  is  about  to  be 
performed,  it  is  very  important  that  the  nurse  should  draw 
off  the  urine  with  a  catheter  just  prior  to  the  patient's 
entering  the  operating  room.  If  this  precaution  is  neglected, 
perhaps  because  the  patient  has  recently  passed  her  water, 
the  surgeon  may  be  in  danger  of  wounding  the  bladder  ; 
for  the  kidneys  act  very  quickly  during  the  anxious  moments 
just  preceding  the  operation,  and  if  the  patient  micturates 
naturally,  it  may  happen  that  she  does  not  completely 
empty  the  bladder,  or  the  urine  may  accumulate  so  quickly 
that  this  organ  is  found  at  the  operation  to  be  distended. 

If  the  nurse  has  any  difficulty  in  passing  the  catheter 
and  drawing  off  the  water,  she  must  be  sure  to  tell  the 
operator,  as  this  may  be  an  indication  that  the  bladder 
is  displaced,  and  the  operator  will  then  use  extra  care 
in  opening  the  peritoneal  cavity. 

Dress  and  food. — -As  for  minor  operations  (p.  82). 
If  the  patient  is  very  weak  she  should,  if  possible, 
be  fed  up  and  stimulants  and  tonics  given  before  the 
operation. 

II.  PREPARATION  OF  THE  STAFF  AND  PATIENT 
AT  THE  OPERATION 

The  surgeon  and  assistants. — Having  removed  what 
articles  of  clothing  they  consider  it  necessary  to  dispense 
with,  the  surgeons  and  assistants  prepare  their  hands 
and  arms.  These  should  be  thoroughly  scrubbed  with 
a  nail-brush,   soap,   and    hot   water,   using    two  or  three 


PREPARATION  AT  THE   OPERATION        85 

basinfuls  of  hot  water  or,  better  still,  holding  the  hands 
and  arms  under  running  water.  All  soap  is  then  re- 
moved with  plain  water,  after  which  the  hands  and  arms 
should  be  well  soaked  in  mercurial  solution.  The  swab 
nurse  then  takes  the  sterilized  overalls  from  the  box 
and  puts  them  on  the  surgeon  and  assistants.  In  like 
manner  she  adjusts  the  masks.  The  surgeon  and  his 
assistants  then  put  on  the  sterilized  india-rubber  gloves. 
The  plan  followed  in  America  and  at  some  institutions 
on  the  Continent  of  having  a  suite  of  dressing  and  bath 
rooms  for  the  surgeons  near  the  operating  theatre,  so  that 
the  surgeon  has  facilities  for  dressing  in  a  sterilized  suit 
before  the  operation,  and  having  a  bath  if  he  wishes, 
has  everything  to  recommend  it. 

The  nurses. — The  swab  and  instrument  nurses  should 
wear  sterilized  overalls,  masks,  and  india-rubber  gloves, 
and  should  prepare  their  hands  and  arms  in  a  way  similar 
to  that  described  for  the  surgeon. 

The  patient. — For  vaginal  operations  the  patient,  having 
been  anaesthetized,  is  placed  in  the  lithotomy  position, 
and  the  site  of  the  operation  is  treated.  The  compress  is 
removed  and  the  vulva  thoroughly  douched  with  biniodide 
of  mercury,  1 — 2,000.  Some  ethereal  soap  is  poured  into 
the  vagina,  and  the  canal  is  thoroughly  swabbed  with  a 
wool  swab  on  a  pair  of  ring  forceps,  after  which  it  is  care- 
fully douched  with  biniodide  of  mercury,  1 — 2,000.  Steril- 
ized leggings  are  now  fastened  on  and  a  sterilized  sheet 
with  an  oval  aperture  in  the  centre,  6  in.  by  4,  is  draped 
over  the  abdomen  and  buttocks  so  that  the  operation- 
site  is  alone  exposed. 

Abdominal  operations. — The  patient,  having  been  anaes- 
thetized, is  placed  on  the  operation  table,  and  her  legs 
being  securely  fixed  to  the  leg  pieces,  she  is  tilted  into  the 
Trendelenburg  position.  Her  nightdress  is  then  drawn  up 
round  the  waist,  and  the  bandage  and  dressing  are  removed 
by  the  general  nurse.  The  second  assistant  now  takes 
sterilized  towels   from   the   box   and  places   one   over  the 


S6  GYNECOLOGICAL   SURGERY 

chest  of  the  patient,  one  over  each  arm,  and  one  over  the 
pubes  and  the  blanket  covering  the  legs.  By  this  means 
the  operation  area  is  surrounded  by  sterilized  towels. 
Over  these  again  a  sterilized  "  operation  sheet  "  is  now 
placed.  This  consists  of  a  large  sheet  having  an  oval 
aperture  in  its  middle  which  sufficiently  exposes  the  area 
of  the  abdomen  to  be  incised  and  no  more.  If  the  abdomen 
has  been  previously  prepared.,  no  further  treatment  of 
this  kind  is  absolutely  necessary,  but  as  an  additional  pre- 
caution, especially  where  the  perfect  preparation  of  the 
patient  beforehand  cannot  be  guaranteed,  the  abdomen 
may  be  swabbed  with  absolute  alcohol,  the  site  of  the 
incision  may  be  again  scrubbed  with  a  nail-brush,  soap, 
and  hot  water,  and  finally  swabbed  with  a  i — 1,000  solution 
of  biniodide  of  mercury  in  a  mixture  of  spirit  and  water, 
3  to  i.  In  cases  of  abdominal  panhysterectomy  for  malig- 
nant disease,  the  patient,  before  she  is  anaesthetized,  should 
have  her  vagina,  after  a  final  douche,  lightly  packed  with 
sterilized  gauze,  which  will  collect  any  pus  or  malignant 
debris  that  is  disturbed  during  the  necessary  abdominal 
manipulations,  and  this  gauze  should  be  withdrawn  during 
the  operation  by  the  general  nurse  just  before  the  vagina 
is  opened,  so  as  to  obviate  the  risk,  as  far  as  possible,  of 
any  septic  material  escaping  into  the  pelvic  cavity.  It  is 
in  such  cases  also  that  we  strongly  advise  the  use  of  steril- 
ized india-rubber  sheeting  for  covering  the  edges  of  the 
wound. 

The  anaesthetic — The  anaesthetic  is  better  administered 
in  another  room,  but  if  the  operation  must  take  place  in 
the  room  the  patient  is  occupying,  or  if  she  must  be  anaes- 
thetized in  the  operating-theatre,  then  all  the  instruments 
and  appliances  should  be  covered  over  with  sterilized 
towels,  so  that  they  may  be  hidden. 


CHAPTER    VI 
OPERATIONS    ON    THE    VULVA 

URETHRAL    CARUNCLE 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — -Clover's  crutch,  Auvard's  speculum, 
bladder-sound,  Paquelin's  or  other  cautery,  a  pair  of 
fine  rat  -  toothed  forceps,  scissors  or  scalpel,  and  silk 
suture  No.  1. 

There  are  three  different  ways  in  which  a  urethral 
caruncle  can  be  treated  : 

1.  Cauterization. 

2.  Excision  and  cauterization. 

3.  Excision  and  suture. 

Cauterization. — The  point  of  a  bladder-sound,  or,  better 
still,  a  small  three-bladed  urethral  dilator,  is  inserted  into 
the  urethral  orifice  and  pressed  against  the  anterior 
urethral  wall.  This  will  prevent  the  cautery  from  burn- 
ing the  anterior  wall  and  so  favouring  a  stricture.  The 
operator  or  assistant  then  separates  the  labia  majora, 
and  the  caruncle  is  very  thoroughly  destroyed  with  the 
point  of  the  cautery,  which  should  be  heated  to  a  dull- 
red  colour  only.  Finally,  vaseline  is  smeared  over  the 
area  of  operation.     (Fig.  39.) 

Dangers. — If  the  cauterization  is  too  severe,  a  stricture 
at  the  orifice  of  the  urethra  may  result,  which,  however, 
can  be  easily  dealt  with. 

Excision  and  cauterization  or  suture. — The  orifice  of 
the  urethra  is  dilated  as  before,  and  the  caruncle  is  then 

87 


88 


GYNECOLOGICAL  SURGERY 


seized  with  fine  forceps  and  either  dissected  off  the  posterior 
urethral  wall  with  the  scalpel  or  snipped  off  with  a  fine 
pair  of  scissors  ;  the  excision  being  carried  somewhat 
wide  of  the  growth  so  as  to  include  a  small  piece  of  healthy 


Fig.  39. — Cauterization  of 
a  urethral  caruncle. 


mucous  membrane.  The  rather  free  bleeding  is  then  stopped 
either  by  cauterization  or  by  passing  a  fine  suture  from 
one  cut  edge  of  the  mucous  membrane  through  the  under- 
lying muscle  to  the  other  cut  edge  and  tying  it. 
(Fig.  40.) 

Dressing    and    after  -  treatment.  —  See   Chapter    xxxn. 


URETHRAL    CARUNCLE 


89 


Some  patients  after  this  slight  operation  get  retention 
of  urine.  This  may  last  for  one  or  two  days.  It  can  be 
relieved  by  the  usual  methods,  and  is  of  no  serious 
importance.  The  patient  may  be  allowed  to  get  up  the 
next  day. 

Recurrence. — Urethral   caruncles   have   a    marked    ten- 
dency to  recur,  and  in  some  cases  more  than  one  operation 


Fig.  40. — Excision  of  a   urethral  caruncle. 

is  necessary  to  cure  this  condition.  Therefore,  although 
the  operation  is  a  simple  one,  it  behoves  the  operator  to 
do  it  very  thoroughly,  in  order  to  obviate  recurrence  if 
possible.  In  addition,  it  is  desirable  that  the  patient 
should  be  informed  of  this  tendency  to  recurrence,  lest 
on  its  taking  place  she  should  suspect  the  operator  of 
being  unskilful. 


90  GYNAECOLOGICAL  SURGERY 

PROLAPSE     OF    THE     URETHRA 
Preparation  of  the  patient. — See  pp.  78-82. 
Instruments. — Clover's   crutch,    dissecting   forceps,   two 

pairs  of  Spencer  Wells  forceps,  two  curved  needles  No.  13, 

scissors,  and  silk  No.  1. 

Operation. — That    portion    of    the    urethra     which     is 


.  Fig.  41. — Transfixion  of  prolapsed  urethra. 

prolapsed  is  caught  with  pressure-forceps  and  drawn  for- 
wards so  as  to  put  it  on  the  stretch.  A  suture  is  then 
passed  across  the  urethral  canal,  in  its  passage  transfixing 
the  prolapsed  mucous  membrane  (Fig.  41).  The  mucous 
membrane  in  front  of  the  suture  having  been  removed  with 
scissors  (Fig.  42),  that  portion  of  the  suture  which  can  be 
seen  traversing  the  urethral  canal  is  pulled  down  out  of 
the  canal  and  divided  so  that  two  sutures  are  now  avail- 
able  (Fig.  43),  one  to  anchor  the  cut  mucous  membrane 


SUBURETHRAL  ABSCESS 


9i 


to  the  orifice  on  the  left  side  and  the  other  for  the  same 
purpose  on  the  right  side.  These  sutures  having  been 
tied,  the  cut  edge  of  mucous  membrane  is  sutured  to  the 
urethral  orifice  with  as  many  interrupted  sutures  as 
may  be  found  necessary  (Fig.  44). 

Complications. — This  operation  may  result  in  a  slight 
amount  of  stricture  at  the  urethral  orifice  if  the  operator 
has  improperly  cut  away  part  of  the  mucous  membrane 


Fig.  42. — Removal  of  the  prolapsed 
urethra. 


of  the  vestibule  instead  of  limiting  the  excision  to  that  of 
the  urethra. 

Dressing  and  after-treatment. — See  Chapter  xxxn.  It 
is  usual  to  allow  the  patient  to  get  up  at  the  end  of  a 
week. 

SUBURETHRAL   ABSCESS 
Preparation  of  the  patient. — See  pp.  78-82. 
Instruments. — Clover's     crutch,      Auvard's     speculum, 
scalpel,  dissecting  forceps,  two  pairs  of  pressure-forceps. 


92 


GYNAECOLOGICAL  SURGERY 


Operation. — The  abscess  is  incised,  the  pus  evacuated, 
and  the  cavity  thoroughly  swabbed  with  pure  carbolic 
acid. 

Dressing  and  after-treatment. — The  cavity  is  packed 
with  iodoform,  sal-alembroth,  or  sterile  gauze.     The  general 


Fig.    43. — Prolapsed   urethra  :    Fixation 
of  the  mucous  membrane. 


lines  of  after-treatment  are  described  in  Chapter  xxxn. 
The  gauze  is  removed  the  day  following  the  operation, 
after  which  the  cavity  is  irrigated  with  biniodide  of 
mercury,  i — 4,000,  and  then  packed  lightly  every  day 
until  healing  by  granulation  has  taken  place.  The 
patient  is  able  to  get  up  as  soon  as  the  purulent  discharge 
ceases. 


URETHROCELE 

URETHROCELE 


93 


Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Auvard's  speculum,  Clover's  crutch,  blad- 
der sound,  scalpel,  dissecting  forceps,  two  pairs  of  pressure- 
forceps,  scissors,  curved  needle  No.  13,  silk  sutures  No.  1. 

Operation. — A  bladder  sound  is  passed  through  the 
urethra  into  the   urethrocele.     An  incision  is  then  made 


f&t 


Fig.  44. — Prolapsed   urethra  :    Suturing  the  mucous 
membrane. 

through  the  mucous  membrane  of  the  vagina  on  to  the 
point  of  the  sound,  so  that  the  sacculated  portion  of  the 
urethra  is  opened.  The  urethrocele  is  then  excised,  together 
with  that  portion  of  the  vaginal  wall  which  covers  it. 
The  hole  in  the  urethra  is  closed  with  one  or  more  fine 
silk  sutures.  The  opening  in  the  vagina  is  finally  closed  by 
interrupted  silk  sutures  passed  through  the  vaginal  tissue 
but  not  including  the  mucous  membrane  of  the  urethra. 

Dressing    and    after  -  treatment.  —  See    Chapter    xxxn. 
The  patient  can  get  up  in  ten  days. 


94  GYN/ECOLOGICAL  SURGERY 

HYDROSTATIC    DILATATION    OF    THE    BLADDER 

In  certain  cases  of  functional  incontinence  in  young 
women,  after  the  various  methods  of  treatment  by  drugs 
have  been  tried  and  failed,  a  cure  or,  at  any  rate,  great 
improvement  may  be  obtained  by  the  hydrostatic  dilata- 
tion of  the  bladder. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch  and  a  catheter  attached 
to   a  glass  funnel  by  four  feet  of  rubber  tubing. 

Operation. — The  bladder  having  been  emptied  of  urine, 
warm  boric  lotion  is  gradually  run  into  it  from  the  funnel. 
The  pressure  must  be  regulated  so  that  the  bladder  is 
not  distended  too  forcibly,  and  this  is  effected  by  noticing 
the  position  of  the  bladder  per  abdomen  from  time  to 
time  and  holding  the  funnel  containing  the  lotion  about 
4  ft.  above  the  level  of  the  patient.  About  two  pints  of 
the  boric  lotion  is  run  into  the  bladder  and  allowed  to 
remain  there  for  twenty  minutes,  and  then  withdrawn. 

After-treatment. — The  patient  may  get  up  the  next  day. 

IMPERFORATE    HYMEN 
Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  a  pair  of  sponge- 
holding  forceps. 

Operation. — A  small  incision  is  made  in  the  bulging 
hymen  from  before  backwards,  and  the  thick  blood  and 
mucus  allowed  to  escape  without  any  assistance  such  as 
pressure  on  the  uterus.  When  the  flow  of  retained  fluid 
decreases,  the  incision  is  enlarged,  and  another  made  at 
right  angles  to  it ;  but  after  this,  authorities  differ  very 
much  as  to  the  best  treatment.  Some  operators  recom- 
mend that  nothing  else  should  be  done  beyond  the  applica- 
tion of  a  sterilized  diaper,  to  be  changed  whenever  it  is 
soiled.  Others  insist  that  it  is  better  to  try  to  remove 
all  the  retained  fluid  possible  by  gently  irrigating  with  a 
boric-acid  douche. 

We    think    that    if    the  vagina  alone  is  distended  the 


IMPERFORATE  HYMEN  95 

retained  fluid  should  be  evacuated  as  completely  as  possible 
by  swabbing  and  douching,  but  that  where  the  uterus 
itself  is  distended  it  is  better  to  leave  it  to  drain  by  itself. 

Dangers. — The  dangers  connected  with  this  operation 
are  those  of  sepsis  and  haemorrhage. 

Sepsis. — This  is  a  very  real  and  serious  danger,  and 
in  the  past  was  the  cause  of  many  deaths.  Sepsis  is  due 
to  organisms  entering  the  enormously  dilated  genital  tract 
and  finding  therein  a  retained  fluid  upon  which  they  can 
thrive,  multiplying  rapidly.  The  distended  state  of  the 
Fallopian  tubes  which  is  so  often  present  forms  a  direct 
route  to  the  peritoneum,  and  double  suppurating  haemato- 
salpinx  and  general  peritonitis  have  often  resulted. 

Haemorrhage. — This  is  intraperitoneal  in  character,  and 
is  due  to  the  rupture  of  a  dilated  Fallopian  tube  or  tubes. 

The  fact  that  the  Fallopian  tubes  are  dilated  cannot, 
however,  at  first  be  ascertained,  and  for  this  reason  the 
abdominal  swelling  should  not  be  pressed  upon ;  since,  if 
the  tubes  are  distended,  it  is  a  proof  that  their  ampullary 
ends  must  have  been  sealed,  and  the  peritonitis  causing 
this  may  also  have  fixed  them,  so  that  when  pressure  is 
applied  there  is  a  danger  of  their  being  ruptured  or  of 
the  adhesions  fixing  them  being  torn. 

If,  after  evacuation  of  the  retained  fluid  from  the 
vagina,  the  patient  shows  signs  of  intraperitoneal  bleeding, 
the  abdomen  must  be  opened  and  the  condition  dealt  with. 
(See  pp.  129,  216.)  This  also  should  be  done  if  the  Fallopian 
tubes  are  ascertained  by  bimanual  examination  to  be  dilated. 

Dressing  and  after-treatment.  —  See  Chapter  xxxn. 
The  sterilized  pads  are  to  be  removed  when  soiled,  and 
if  the  patient,  by  a  rise  of  temperature,  shows  any  signs 
of  sepsis,  the  vagina  must  be  douched  twice  daily  with  a 
warm  solution  of  biniodide  of  mercury,  1 — 4,000. 

If  definite  signs  of  salpingitis  appear,  the  condition  must 
be  treated  on  the  usual  principles,  remembering  that  it  is 
always  better,  if  possible,  to  postpone  an  operation  until  the 
acute  stage  has  subsided. 


96  GYNECOLOGICAL  SURGERY 

The  patient  should  be  sat  up  during  convalescence  in 
order  that  better  drainage  may  take  place,  and  she  will 
remain  in  bed  until  all  discharge  has  stopped. 

ABSCESS    OF    BARTHOLIN'S    GLAND 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  and  two  pairs  of 
pressure-forceps. 

Operation. — The  abscess  is  opened  by  an  incision 
parallel  with  the  long  axis  of  the  labium  majus  ;  the  upper 
limit  of  the  incision  must  not  reach  too  high,  otherwise 
the  bulb  may  be  injured.  The  pus  having  been  evacuated, 
the  abscess  cavity  is  well  douched  with  biniodide  of  mercury, 
1 — 2,000,  then  swabbed  with  pure  carbolic  acid  and  lastly 
packed  with  sterile  gauze. 

Dressing  and  after-treatment. — The  general  lines  of 
after-treatment  will  be  found  discussed  in  Chapter  xxxn. 
The  gauze  should  be  removed  next  morning,  and  the  cavity 
repacked  twice  daily  after  douching.  Where  there  is  much 
oedema  and  swelling,  hot  fomentations  may  be  applied 
for  some  days  until  it  subsides. 

No  particular  time  can  be  given  for  the  patient  to  get 
up,  as  this  must  depend  on  the  length  of  time  the  cavity 
takes  to  granulate. 

EXCISION    OF    A    BARTHOLINIAN    CYST 

Preparation  of  the  patient. — -Sec  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  six  pairs  of 
pressure-forceps,  dissecting  forceps,  two  half-circle  needles 
No.  9,  two  curved  needles  No.  9,  and  silk  sutures  No.  2. 

Operation. — An  incision  running  parallel  with  the  long 
axis  of  the  labium  majus  down  to  the  cyst-wall  is  made 
with  the  scalpel  (Fig.  45).  This  incision  should  be  at  the 
junction  of  the  skin  and  with  the  mucous  membrane,  so 
that  the  resulting  scar  may  not  cause  dyspareunia.  The 
upper  limit  of  the  incision  must  not  reach  too  high,  other- 
wise  the   bulb   will   be   incised   and   troublesome   bleeding 


BARTHOLINIAN  CYST 


97 


will  result.  A  pair  of  pressure-forceps  is  then  applied  to 
the  cut  edge  of  the  mucous  membrane  and  the  cyst-wall 
is  separated  from  the  surrounding  connective  tissue  with 
the  handle  of  the  scalpel  (Fig.  46).  It  will  be  found  to 
separate  quite  easily  in  all  directions,  unless  it  has  been 
the  seat  of  inflammation,  till  its  upper  and  posterior  surface 


Fig.  45. — Excision  of  Bartholinian  cyst :    Incising 
the  mucous  membrane. 


is  reached.  This  part  will  not  separate  easily,  and  generally 
the  enucleation  has  to  be  finished  by  cutting  with  the 
scalpel  through  the  firm  strands  of  connective  tissue  in 
this  situation  (Fig.  47).  It  is  at  this  more  adherent  part 
that  the  branches  of  the  internal  pudic  artery  and  vein 
are  found,  and  these  will  require  ligaturing  with  No.  2 
silk. 

H 


98 


GYNAECOLOGICAL  SURGERY 


Fig.  47. — Completing 
the  enucleation. 


BARTHOLINIAN  CYST 


99 


When  enucleating  the  cyst,  care  must  be  taken  not  to 
button-hole  the  vaginal  surface  of  the  labium. 

Apart  from  any  spurting  vessels,  it  is  sometimes  very 
difficult  to  control  oozing  from  the  venous  plexus  in  the 
bed  of  the  cyst ;  and  since  this  bed  is  sometimes  rather  large, 


Obliterating  the  cavity  left. 


and  if  not  obliterated  would  form  a  pocket  in  which  blood 
could  accumulate,  it  is  best  to  bring  its  raw  edges  together 
by  interrupted  silk  sutures  applied  inside  the  cavity, 
commencing  at  the  bottom  and  gradually  obliterating  it 
(Fig.  48). 

The  edges  of  mucous  membrane  are  then  sutured  with 
a  continuous  suture  (Fig.  49). 


100 


GYNECOLOGICAL  SURGERY 


Difficulties. — Some  difficulty  may  be  experienced  in 
enucleating  the  cyst  if  it  has  been  inflamed  and  the  wall 
is  consequently  adherent  to  the  surrounding  structures,  or 
if  during  its  enucleation  the  cyst  is  punctured. 

Dangers.  Bleeding. — Rarely,  owing  to  a  ligature  hav- 
ing  slipped,  secondary  haemorrhage  may  take  place  to  a 


Fig.  49.— Closure  of 
the  wound. 


serious  extent,  forming  a  large  hsematoma.  If  this  occurs, 
and  pressure  with  a  firm  pad  of  cotton-wool  and 
T-bandage  does  not  stop  it,  the  patient  will  have  to  be 
anaesthetized,  the  sutures  removed,  and  the  bleeding-point 
secured. 

Sepsis. — If  the  cyst  is  suppurating  and  is  punctured 
during  its  enucleation,  the  pus  will  soil  the  seat  of  operation, 
and  this  part  will,   therefore,   have  to   be  most  carefully 


VARICOSE    VEINS    OF    VULVA  101 

cleaned  with  biniodide  of  mercury,  i — 1,000.  The  cavity 
should  be  drained  for  a  few  days  with  an  india-rubber  tube 
in  such  cases. 

Dressing  and  after-treatment. —  See  Chapter  xxxn. 
The  patient  requires  to  be  kept  in  bed  for  about  ten  days. 

HYDROCELE    OF    THE    CANAL    OF    NUCK 

Preparation  of  the  patient. — See  pp.  78-82. 

Position  of  the  patient. — Lying  flat  on  the  table. 

Instruments. — Scalpel,  scissors,  dissecting  forceps,  four 
pairs  of  pressure-forceps,  four  curved  needles  No.  7,  silk 
sutures  Nos.  2  and  4. 

Operation. — An  incision  is  made  through  the  skin  over 
and  parallel  with  the  long  diameter  of  the  swelling,  care 
being  taken  to  avoid  wounding  the  wall  of  the  sac.  The 
sac,  having  been  exposed  and  opened,  and  its  contents 
evacuated,  is  dissected  out  and  its  neck  of  communication 
with  the  peritoneum,  if  it  exists,  is  ligatured  with  No.  2 
silk.  If  the  internal  abdominal  ring  seems  unduly  large, 
it  should  be  closed  with  one  or  two  interrupted  sutures 
passed  through  the  arching  border  of  the  transversalis 
and  the  internal  oblique  muscles  and  Poupart's  ligament 
respectively.  The  external  abdominal  ring  is  closed  with 
a  couple  of  No.  4  silk  sutures.  Any  bleeding  having  been 
stopped  with  ligatures  or  pressure-forceps,  the  skin  incision 
is  closed  with  a  few  interrupted  silk  sutures. 

Dressing. — This  consists  of  gauze,  wool,  and  a  spica 
bandage. 

After-treatment. — See  Chapter  xxxn.  The  skin-stitches 
will  be  removed  at  the  end  of  a  week,  and  the  patient 
can  get  up  in  ten  days. 

VARICOSE   VEINS   OF   THE   VULVA 

As  a  result  of  pregnancy,  and  even  apart  from  it, 
the  veins  of  the  vulva  may  become  varicose.  In  some 
patients,  during  pregnancy,  so  bad  is  the  condition  that 
labour  has  to  be  induced  to  avoid  rupture  of  the  veins  or 


102  GYNECOLOGICAL  SURGERY 

obstruction  during  delivery.  Varicose  veins  of  the  vulva 
must  not  be  excised  during  pregnancy. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  dissecting  forceps, 
scissors,  six  pairs  of  pressure-forceps,  aneurysm-needle,  silk 
ligatures  and  sutures  No.  2,  and  four  curved  needles  No.  7. 

Operation. — The  labium  of  the  affected  side  must  be 
stretched  so  that  the  skin-incision  over  the  dilated  veins 
may  be  accurately  made.  This  can  be  done  by  an  assistant 
pulling  on  the  upper  end  of  the  labium  while  the  operator 
pulls  on  the  lower  end  ;  or  the  operator  may  stretch  the 
labium  between  the  thumb  and  index-finger  of  his  left 
hand.  An  incision  is  then  made  through  the  skin  down 
to  the  varicose  veins.  The  skin-edges  being  held  apart, 
the  veins  are  dissected  from  their  bed  with  the  handle 
of  the  scalpel  and  dissecting  forceps.  The  veins,  having 
been  well  freed,  are  ligatured  as  far  apart  as  possible  at  the 
upper  and  lower  angle  of  the  wound  with  No.  2  silk  passed 
on  an  aneurysm-needle,  after  which  the  portion  between 
the  ligatures  is  excised.  Any  oozing  having  been  arrested, 
the  skin-incision  is  closed  with  a  few  interrupted  sutures 
of  No.  2  silk. 

Dressing  and  after-treatment. —  See  Chapter  xxxn. 
The  patient  may  get  up  at  the  end  of  ten  days,  the 
stitches  having  been  removed  after  a  week. 

HEMATOMA  OF  THE  VULVA 

If  the  effused  blood  is  not  absorbed  with  the  usual 
treatment  of  cold  compresses,  or  if  it  appears  likely  to 
suppurate,  then  the  clot  should  be  turned  out. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  dissecting  forceps, 
four  pairs  of  pressure-forceps,  four  curved  needles  No.  7, 
silk  sutures  No.  2. 

Operation. — An  incision  is  made  over  the  swelling 
through  the  skin  down  to  the  effused  blood.  The  blood- 
clot  is  turned  out,   after  which  the  cavity  is  thoroughly 


EXCISION  OF  VULVA  103 

douched  with  a  solution  of  biniodide  of  mercury,  1 — 2,000. 
Any  bleeding-points  having  been  ligatured  with  No.  2 
silk,  the  edges  of  the  incision  are,  lastly,  brought  together 
with  interrupted  sutures  passed  deep  to  the  cavity  so 
that  the  latter  is  obliterated  when  the  sutures  are  tied. 

If  suppuration  has  taken  place,  the  operation  is  per- 
formed in  a  similar  way,  but  in  this  case  the  cavity  is 
packed  with  gauze  and  the  wound  allowed  to  granulate  up. 

Dressing  and  after-treatment.  —  See  Chapter  xxxil. 
If  suppuration  has  not  occurred,  the  patient  can  get  up 
in  ten  days,  the  skin  sutures  having  been  removed  in  a 
week  ;   otherwise  she  must  rest  till  granulation  is  complete. 

WARTS    OF    THE    VULVA 

If  the  ordinary  treatment  of  cleanliness  and  oxide  of 
zinc  powder  does  not  cure  the  warts,  or  if  they  are  too 
large  to  be  treated  in  this  way,  then  they  should  be  removed. 
The  bleeding  may  be  very  smart,  especially  if  the  warts 
have  to  be  removed  in  pregnancy. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scissors  curved  on  the 
flat,  dissecting  forceps,  six  pairs  of  pressure-forceps,  four 
curved  needles  No.  7,  silk  No.  4. 

Operation. — The  warts  should  be  removed  with  the 
scissors,  after  which  the  raw  surfaces  are  closed  with 
mattress-sutures. 

Dressing  and  after-treatment. — 'See  Chapter  xxxn. 
The  sutures  are  removed  in  seven  days,  and  the  patient 
gets  up  three  days  later. 

EXCISION   OF  PART  OR  WHOLE  OF  THE  VULVA 

Indications. — -The  vulva  may  be  removed  in  whole  or 
in  part  for  cancer,  tubercle,  leucoplakic  vulvitis,  or  hyper- 
trophy of  the  clitoris  or  labia  due  to  elephantiasis  or  syphilis. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments — Clover's  crutch,  bladder-sound,  scalpel, 
twelve    pairs     of    pressure-forceps,    scissors,    three    curved 


io4  GYNAECOLOGICAL  SURGERY 

needles   No.    7,    three   curved   needles    No.    3,    silk   Nos.  2 
and  4,  stout  silkworm-gut. 

Operation  for  complete  excision. — An  oval  incision 
is  made  with  the  scalpel  through  the  skin  and  subcutaneous 
tissue  down  to  the  deep  fascia  and  well  clear  of  the  disease. 
The  incision  commences  above  the  clitoris  on  each  side, 
includes  both  labia  majora,   and  ends  posteriorly  to   the 


Fig.  50. — Excision  of  vulva  :  Making  the  outer  incision. 

fourchette  (Fig.  50).  A  second  incision  is  now  made  round 
the  urinary  meatus  and  the  vaginal  orifice  (Fig.  51).  The 
structures  lying  between  these  two  incisions  down  to  the 
deep  fascia  are  then  dissected  away  in  a  single  piece,  all 
spouting  vessels  being  clamped  for  the  time  being  with 
pressure-forceps  and  ligatured  with  silk  after  the  growth 
has  been  removed  (Fig.  52). 

At  times  there  is  very  troublesome  bleeding,  especially 


EXCISION  OF  VULVA 


105 


from   the   dorsal   artery  of    the    clitoris  and  some   of  the 
large    vestibular    vessels,    and   it    is    difficult    to    pick    up 


Fig.  51.— Making  the 
inner  incision. 


the  bleeding-point,  in  which  case  the  haemorrhage  can  be 
effectually  controlled  by  passing  a  mattress-suture  under 
the  bleeding  area. 


Fig.  52. — Excising  the  diseased  area. 


io6 


GYNAECOLOGICAL  SURGERY 


The  right  and  left  edges  of  the  outer  incision  above 
the  level  of  the  urethral  orifice  are  now  approximated  with 
interrupted  silkworm-gut  sutures  passed  deeply  to  the 
raw  surface.  Below  this  level  the  cut  edges  of  the  skin 
and  vagina  respectively  are  similarly  united  (Fig.  53). 

If  there  is  any  difficulty  in  approximating  the  cut  edges 
of  the  skin  and  vagina,  the  lower  end  of  the  vagina  should 
be  freed  for  about  an  inch  so  that  it  can  be  pulled  down 
and  brought  into  close  apposition  with  the  skin  edge,  thus 


Fig.  53. — Suturing  the  wound. 


covering  the  raw  surface  left  after  the  removal  of  the 
growth. 

Removal  of  inguinal  glands. — In  all  cases  of  malig- 
nant disease  of  the  vulva  the  inguinal  glands  on  both 
sides  should  be  removed,  whether  enlarged  or  not.  Some 
authorities  prefer  to  remove  these  glands  from  seven  to 
fourteen  days  after  the  primary  operation,  but  we  our- 
selves think  it  is  preferable,  when  possible,  to  finish  the 
operation  at  one  sitting. 

The  removal  of  the  glands  is  best  carried  out  after 
the  vulva  has  been  excised  and  all  the  bleeding-points 
secured.     The  leg  on  the  side  to  be  first  dealt  with  having 


EXCISION  OF  VULVA 


107 


been  extended,  an  incision  should  be  made  running  up- 
wards and  outwards  parallel  with  Poupart's  ligament  and 
starting  from  the  upper  part  of  the  already  denuded  area. 
The  skin-edges  of  this  incision  having  been  turned  back,  all 
the  soft  tissues  down  to  the  aponeurosis,  including  of  course 
the  horizontal  inguinal  glands,  should  be  dissected  out  in 
one  piece,  starting  at  the  outer  angle  of  the  incision  (Fig.  54). 


-Removing  the  inguinal 
glands. 


All  bleeding-points  having  been  secured,  the  inguinal 
incision  should  be  closed  with  interrupted  silkworm-gut 
sutures,  after  which  the  thigh  is  flexed,  and  the  other  side 
is  similarly  dealt  with. 

The  patient  being  restored  to  the  lithotomy  position, 
the  vulval  wound  is  united  in  the  manner  previously 
described  (Fig.  53). 


108  GYNECOLOGICAL  SURGERY 

Danger. — If  the  growth  is  large  and  the  clitoris  and 
labia  minora  are  affected,  there  may  be  some  difficulty  in 
dissecting  the  mass  away  without  injuring  the  urethra. 
It  will  be  found  safer  in  these  circumstances  to  put  a 
bladder-sound  into  the  urethra  whilst  the  structures  in 
its  neighbourhood  are  being  removed. 

There  is  also  a  danger  in  these  cases  that,  if  sloughing 
occurs  in  the  neighbourhood  of  the  urethra,  the  resulting 
contraction  of  the  tissues  round  its  orifice  may  result  in 
serious  difficulty  with  micturition. 

Dressing. — The  vulval  wound  is  covered  with  dry  gauze 
held  in  position  by  a  T-bandage.  If  the  inguinal  glands 
have  been  removed,  dry  dressings  and  a  spica  bandage 
are  applied  to  each  side. 

After-treatment.  —  The  general  lines  of  after-treat- 
ment will  be  found  in  Chapter  xxxn.  It  will  be  necessary 
to  use  the  catheter  for  the  first  week  after  the  operation, 
so  as  to  prevent  the  wound  from  being  contaminated  with 
urine. 

After  this  operation  pain  is  generally  a  marked  feature, 
being  due  to  the  tension  on  the  stitches  ;  this  can  be  relieved 
by  morphia. 

Owing  to  the  situation  of  the  wound  and  the  nature 
of  the  disease  for  which  the  operation  is  generally  under- 
taken, there  is  a  liability,  even  with  the  greatest  care,  for 
a  certain  amount  of  suppuration  to  occur,  and  at  times  this 
is  very  marked,  resulting  in  high  fever  with  considerable 
constitutional  disturbance.  If  inflammation  intervenes,  any 
sutures  causing  injurious  tension,  suppuration,  or  inter- 
ference with  free  drainage  are  to  be  removed,  and  hot 
fomentation  should  be  applied  every  four  hours. 

In  the  more  severe  cases,  with  sloughing,  the  parts 
should  be  irrigated  with  a  io-volume  solution  of  peroxide 
of  hydrogen  before  the  application  of  each  new  fomentation. 
The  sutures  in  the  groin  may  be  removed  at  the  end  of  a 
week,  the  remaining  sutures  may  be  left  in  a  day  or  two 
longer. 


PERINEOPLASTY  109 

If  the  wound  heals  by  first  intention  the  patient  may 
get  up  in  a  fortnight  to  three  weeks. 

Partial  excision. — The  operation  of  partial  excision  is 
carried  out  on  the  same  lines,  but  the  area  of  removal 
is  smaller.  The  ablation  of  enormously  hypertrophied 
nymphae  is  associated  with  extraordinarily  free  haemor- 
rhage, and  many  pressure-forceps  should  be  at  hand. 

CLITORIDECTOMY 

The  clitoris  is  occasionally  removed  when  hypertrophied. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  four  pairs  of 
pressure-forceps,  dissecting  forceps,  three  curved  needles 
No.  7  and  three  No.  3,  silk  sutures  Nos.  2  and  4. 

Operation. — -The  skin  is  incised  round  the  base  of  the 
diseased  organ,  and  the  clitoris  is  then  separated  and  severed 
at  its  junction  with  the  pubic  arch.  As  the  arteries  of 
the  clitoris  are  cut,  their  mouths  are  seized  with  pressure 
forceps,  after  which  they  are  secured  with  No.  2  silk  liga- 
tures. Any  bleeding,  which  at  times  may  be  very  free, 
can  be  controlled  by  pressure  and  by  the  sutures  of  No.  4 
silk,  which  are  inserted  to  bring  the  skin-edges  together, 
being  passed  deep  to  the  raw  surface. 

Dressing  and  after-treatment. — -See  Chapter  xxxii. 
The  patient  can  get  up  in  ten  days. 

PERINEOPLASTY 

Indications.— This  operation  is  performed  for  an  old 
ruptured  perineum,  a  relaxed  vaginal  outlet,  rectocele, 
cystocele,  or  prolapse — either  to  cure  these  conditions  or 
to  render  possible  the  wearing  of  a  pessary. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  sharp  angular  and  flat 
blunt-pointed  scissors,  eight  pairs  of  pressure-forceps,  rat- 
toothed  dissecting  forceps,  perforated  shot  and  coil,  curved 
needles  Nos.  1  and  7,  shot  compressor,  silkworm-gut  and 
silk  sutures  No.  1. 


no 


GYN/ECOLOGICAL  SURGERY 


i.  The  operation  for  incomplete  rupture. — This  opera- 
tion aims  at  extending  the  perineum  forwards  so  that  its 
anterior  edge  just  covers  the  vaginal  inlet. 

i.  Demarcation  of  flap. — The  operator  inserts  the 
points  of  a  pair  of  angular  scissors  in  the  middle  line  just 
behind  the  posterior  limit  of  the  vaginal  outlet.  The 
buried  blade  of  the  scissors  is  then  slipped  under  the  mucous 


Fig.  55. — Perineoplasty 

(incomplete)  :  The  skin 

incision. 


membrane  on  the  left  side  in  an  upward  direction  and 
internally  to  the  labium  minus  till  its  point  is  just  above 
the  level  of  the  posterior  extremity  of  that  structure. 
The  blades  of  the  scissors  are  then  closed  so  that  the 
mucous  membrane  is  incised  at  the  line  of  its  junction 
with  the  skin  (Fig.  55).  A  similar  incision  is  now  made 
on  the  right  side,  care  being  taken  that  the  upper  limits 
of  each  incision  are  on  the  same  level. 

ii.  Reflecting    the    vaginal    flap. — A   flap   of    mucous 


PERINEOPLASTY 


in 


membrane  is  thus  marked  out,  and  the  next  step  consists 
in  dissecting  up  this  flap  as  far  as  the  upper  limit  of  the 
incisions  (Fig.  56).  If  the  right  plane  of  tissue  be  struck, 
the  dissection  can  often  be  accomplished  with  the  point 
of  the  index  finger  alone,  or  by  swab  pressure,  otherwise 
separation  must  be  effected  with  the  scissors  ;    in  either 


Fig.  56.— Reflecting  the 
vaginal  flap. 


case  the  flap  of  mucous  membrane  as  it  is  raised  must  be 
supported  and  kept  on  the  stretch  by  one  or  two  pairs 
of  forceps  fixed  to  its  free  edge  and  held  by  the  assistant. 
Some  operators  still  introduce  the  first  and  second  fingers 
of  the  left  hand  into  the  rectum  so  as  to  keep  the  recto- 
vaginal septum  on  the  stretch.  By  this  manoeuvre  there 
is  less  danger  of  wounding  the  rectum,  but  if  it  is  practised 
a    clean    glove   should   be   put    on    after   the    fingers    are 


112 


GYNECOLOGICAL  SURGERY 


withdrawn.  The  operation  can  be  better  performed  after 
a  little  experience  without  inserting  the  fingers  into  the 
rectum,  for  the  chance  of  infecting  the  wound  is  diminished. 
The  flap  of  mucous  membrane  having  been  thoroughly 
freed,  particularly  at  the  sides  of  the  vagina,  a  V-shaped 
portion  with  its  apex  towards  the  cervix  is  excised  (Fig.  57). 
The  reason  we   advocate  the  removal   of  this  portion   of 


Fig.  57. — Fashioning 
the  vaginal  flap. 


the  flap  is  that  if  a  case  of  incomplete  rupture  of  the  peri- 
neum be  carefully  examined  after  healing  has  taken  place, 
it  is  evident  that  there  is  more  mucous  membrane  on  the 
posterior  vaginal  wall  than  was  present  before  the  injury. 
This  increase  is  due  to  the  fact  that  the  raw  surfaces  which 
resulted  from  the  laceration,  instead  of  becoming  approxi- 
mated, are  covered  over  with  a  new  mucous  membrane, 
and  a  condition  more  approaching  the  normal  is  secured 
if    this    piece    of   tissue    is    cut    off,  for    on    suturing    the 


PERINEOPLASTY 


"3 


gap    the   correct   forward    curve    of   the    vaginal    canal   is 
restored. 

iii.  Restoring  the  posterior  vaginal  wall. — The  free 
ends  of  the  V-incision  are  now  held  in  two  pressure  forceps 
(Fig.  58),  while  the  gap  in  the  reflected  flap  of  mucous 
membrane  is  closed  with  interrupted  catgut  sutures  on  a 
curved  needle,  commencing  at  the  apex  of  the  incision  and 


ending  at  the  points  of  the  forceps,  the  sutures  being  tied 
so  that  the  knots  lie  outside  the  vagina  (Fig.  59). 

iv.  Approximating  the  edges  of  the  levator  ani 
muscles.- — Where  great  relaxation  of  the  vaginal  outlet 
is  present,  it  is  proper  to  unite  the  levator  ani  muscles 
behind  the  vagina.  The  edges  of  these  muscles  appear 
in  the  depths  of  the  wound  as  a  couple  of  ridges,  one  on 
either  side.  These,  being  defined,  are  united  in  the  middle 
line  by  several  No.  1  silk  sutures  passed  on  a  small  curved 
1 


IT4 


GYNAECOLOGICAL  SURGERY 


needle.  Simple  interrupted  sutures  may  be  used,  but  if 
there  is  much  oozing,  mattress-sutures  are  better,  on  account 
of  their  haemostatic  effect.  It  is  not,  however,  necessary  to 
unite  the  muscles  by  buried  sutures  in  all  cases,  the  ordinary 
deep  sutures  now  to  be  described  being  usually  sufficient. 


Fig.  59. — Restoring  the  posterior  vaginal  wall. 


v.  Introduction  of  the  deep  sutures. — A  new  posterior 
vaginal  wall  having  now  been  fashioned  of  mucous  membrane, 
the  edges  of  the  skin-incision  are  trimmed  up  with  scissors, 
and  silkworm-gut  sutures  on  a  curved  needle  are  intro- 
duced,   the   needle   entering   at   a  point   in   the   skin   just 


PERINEOPLASTY 


115 


external  to  the  raw  surface  on  the  right  side,  emerging 
at  the  corresponding  point  on  the  left  side.  Whilst  the 
suture  is  being  passed  it  should  be  kept  as  deep  as  possible, 
but  the  rectum  should  not  be  penetrated,  and  therefore, 
if  the  operator  has  not  had  his  finger  in  the  rectum  during 


Fig.   60. — Introduction 
of  deep  sutures. 


the  introduction  of  the  sutures,  he  should  make  certain 
before  tying  them  that  their  position  is  correct. 

Three  or  four  such  sutures  are  passed,  the  most  anterior 
one  corresponding  to  the  upper  limit  of  the  incision,  and 
their  ends  are  temporarily  secured  by  a  pair  of  pressure- 
forceps  (Fig.  60). 

vi.  Restoring  the  perineum. — After  all  blood-clot  has 
been  washed  away  with  a  hot  mercurial  douche,   the  silk- 


n6 


GYNECOLOGICAL  SURGERY 


worm-gut  sutures  are  secured  in  turn,  commencing  at  the 
most  posterior,  the  assistant  meanwhile  holding  the  others 
out  of  the  way.  The  two  ends  of  a  suture,  having  been 
cut  level,  are  threaded  through  the  coil  of  silver  wire 
and  afterwards  through  the  perforated  shot,  which  is 
forced  home  by  holding  it  gently  with  the  shot  compressor. 


Fig.  61. — Securing  the  deep  sutures. 


When  the  edges  of  the  raw  surface  are  approximated  and 
the  tension  appears  to  be  sufficient,  the  shot  is  forcibly 
crushed,  after  which  the  free  ends  of  the  suture  are  cut  off 
about  half  an  inch  from  the  shot  (Fig.  61). 

The  other  sutures  in  turn  are  treated  in  a  similar  fashion 
until  with  the  tightening  of  the  last  the  wound  is  com- 
pletely closed. 

An  additional  suture  is  then  inserted,  if  necessary,  on 


PERINEOPLASTY 


117 


each  side  externally  to  the  middle  line,  to  anchor  the  flap 
of  mucous  membrane  to  the  skin  (Fig.  62). 


Fig.  62. — Anchoring  the  vaginal  edge  to  the  skin. 

2.  The   operation  for  complete  rupture. — In    complete 
rupture  the  rectum  is  implicated,  so  that  the  vaginal  and 


Fig.  63. — Perineoplasty  (complete)  :  General  view  of  a 
complete  rupture. 

rectal  canals  at  their  lower  ends  become  conterminous  and 
the  patient  loses  control  over  flatus  and  faeces   (Fig.  63). 


n8 


GYNECOLOGICAL  SURGERY 


The  operation  about  to  be  described  aims  at  restoring 
the  vaginal  and  rectal  canals  and  forming  a  new  perineal 
body  between  these  two  structures. 

i.  Demarcation  of  the  anterior  flap.  —  The  points  of 
the  angular  scissors  being  inserted  at  the  left  external 
limit  of  the  recto-vaginal  septum,  the  incision  is  carried 
across  its  free  edge  (Fig.  64).    The  incision  is  then  continued 


Fig.  64. — Splitting  the  recto- 
vaginal septum. 


up  on  the  left  side,  and  afterwards  on  the  right,  in  the 
manner  described  on  p.   no  (Fig.  65). 

ii.  Separating  the  sides  of  the  rectum. — The  points 
of  the  scissors  are  now  inserted  at  the  external  limits  of 
the  recto- vaginal  septum,  and  the  skin  is  incised  posteriorly 
for  half  an  inch  on  each  side  of  the  anus  externally  to  the 
lacerated  sphincter,  so  that  all  the  incisions  taken  together 
form  more  or  less  the  shape  of  the  letter  H,  and  the 
lower  end  of  the  rectum  is  separated  at  its  sides  (Fig. 
66).  A  pressure-forceps  is  now  applied  at  each  angle  of 
the  vaginal  flap,  while  others   are   attached   to   the    outer 


PERINEOPLASTY 


119 


Fig.  65. — Demarcating 
the     anterior     vaginal 
flap. 


Fig.  66. — Separating  the  sides  of  the  rectum. 


120  GYNECOLOGICAL  SURGERY 

ends  of  the  lacerated  sphincter  muscle  of  the  rectum 
(Fig.  67). 

iii.  Splitting  the  recto-vaginal  septum. — The  anterior 
flap  is  now  dissected  up  as  described  at  p.  111  (Fig.  68), 
and  a  V-shaped  piece  is  excised  (Fig.  69). 

iv.  Restoring  the  posterior  vaginal  wall. — The  ante- 
rior flap   is  then  sutured  with  an  interrupted  silk  suture 


Fig.  67. — Applying  the  marking  forceps. 

as  described  at  p.  113,  and  the  new  posterior  vaginal  wall 
is  thus  fashioned. 

v.  Restoring  the  anterior  rectal  wall. — The  forceps 
which  have  been  fixed  to  the  outer  ends  of  the  lacerated 
sphincter  are  approximated,  and  the  edges  of  the  gap 
in  the  anterior  rectal  wall,  being  freshened,  are  united 
by  interrupted  silk  sutures  which  include  only  the 
muscular  layer  of  the  rectal  wall,  the  knots  being  tied 
so  that  they  lie  in  the  depth  of  the  perineal  wound 
(Fig.  70). 


Fig.  69. — Fashioning  the  vaginal  flap 


122 


GYNECOLOGICAL  SURGERY 


vi.  Restoring  the  perineum. — The  perineum  is  now 
restored  by  drawing  together  the  lateral  margin  of  the 
wound  with  deeply  inserted  sutures  of  silkworm-gut, 
fastened  with  shot  and  coil.  Of  these  sutures  the  posterior 
one  is  most  important  because  it  completes  the  approxima- 


Fig.  70. — Restoring  the  anterior  rectal  wall. 

tion  of  the  lacerated  sphincter  (Figs.  71  and  72).  If  it  is 
deemed  necessary,  the  edges  of  the  levator  ani  muscles  may 
be  separately  united  by  buried  sutures  (p.  113). 

Dangers,  i.  Sepsis. — Owing  to  the  situation  of  the 
wound,  and  the  impossibility  of  procuring  asepsis,  suppura- 
tion after  perineoplasty  is  a  possibility  in  the  most  favour- 


PERINEOPLASTY 


123 


able  circumstances.  It  does  not  usually  give  rise  to  much 
constitutional  disturbance,  but  occasionally  severe  symptoms 
of  sepsis  may  appear.  Suppuration  is  a  disaster,  since  it  may 
increase  the  deficiency  of  the  perineum.  In  this  event,  no 
further  operation  should  be  undertaken  for  six  months.  If 
the  wound  shows  signs  of  suppuration,  all  stitches  must 
be  immediately  removed  and  fomentations  applied.  Care 
must    be    taken    to    avoid    puncturing    the    rectum    when 


Fig.  71. — Passing  the 
posterior  deep  suture. 


dissecting  up  the  posterior  vaginal  flap,  since  such  an 
accident  will  increase  the  risk  of  infection  of  the  operation 
area,  and  may  lead  to  the  formation  of  a  recto-vaginal 
fistula. 

ii.  Haemorrhage. — As  a  rule  the  rather  free  oozing  stops 
as  soon  as  the  deep  sutures  have  been  passed  and  tied, 
but  if  there  are  any  spurting  vessels,  or  if  the  venous  oozing 
is  very  marked,  the  bleeding-points  must  be  secured  with 
mattress-sutures  or  ligatures  of  fine  silk,  for  if  this  be  not 


124 


GYNECOLOGICAL  SURGERY 


done,  and  the  bleeding  continues,  either  a  haematoma  will 
form  under  the  flap  with  the  result  that  the  wound  will 
break  down  in  a  day  or  two,  and  perhaps  suppurate,  or 
the  patient  will  have  to  be  again  anaesthetized,  the  wound 
opened  up,  and  the  bleeding-spots  secured. 

It  is  as  well  to  remember  that  an  alarming  amount  of 
bleeding  may  take  place  into  the  wound  without  much 
external  evidence,  and  we  recall  a  case  where  a  patient  in 


Fig.  72. — Securing  the 
deep  sutures. 


these  circumstances  nearly  bled  to  death,  a  fatal  issue  being 
averted  only  by  an  injection  of  saline  solution  into  the  me- 
dian basilic  veins  after  the  haemorrhage  had  been  arrested. 

Dressing  and  after-treatment. — See  Chapter  xxxn. 
If  after  the  operation  is  finished  marked  oozing  between 
the  stitches  occurs,  it  can  be  arrested  by  plugging  the 
vagina  with  tampons.  The  patient  should  not  get  up 
before  the  twenty-first  day,  the  stitches  being  removed  on 
the  seventh  to  tenth  day. 


DISARTICULATION  OF  COCCYX  125 

REMOVAL   OF   THE   COCCYX      . 

The  coccyx  of  a  woman  may  require  to  be  removed 
because  of  severe  pain  due  to  its  presence.  This  pain 
may  be  neuralgic,  gouty,  or  rheumatic  in  character,  and 
more  or  less  continuous,  or  it  may  trouble  the  patient 
only  in  defalcation  or  in  sitting  down,  in  which  case  the 
coccyx  may  be  found  to  be  fractured,  dislocated,  anky- 
losed,  or  the  seat  of  chronic  arthritis.  In  certain  cases  the 
presence  of  pain  can  only  be  attributed  to  a  neurosis.  Before 
deciding  to  remove  the  coccyx  the  surgeon  must  satisfy 
himself  by  careful  examination  that  the  pain  is  really 
connected  with  this  bone,  and  is  not  due  to  fissure  in 
the  anus  or  some  rectal  trouble. 

Preparation  of  the  patient. — The  perineum,  anus,  cleft 
between  the  two  buttocks,  and  adjoining  skin  should  be 
treated  as  for  perineoplasty   (pp.  78-82). 

Position. — The  patient  should  be  placed  in  the  Sims 
semi-prone  position,  the  buttocks  pointing  towards  the 
window. 

Instruments. — A  scalpel,  pair  of  scissors,  dissecting 
forceps,  six  small  pressure  -  forceps,  bone  -  forceps,  two 
small  retractors,  two  needles  No.  7,  silk  No.  2,  and  silk- 
worm-gut. 

Operation. — The  following  are  the  steps  of  the  pro- 
cedure : — 

i.  Exposure  of  coccyx. — An  incision  is  made  over  the 
posterior  surface  of  the  coccyx  and  the  structure  exposed. 

ii.  Freeing  and  removal  of  coccyx. — The  coccyx  is 
next  seized  with  a  pair  of  forceps,  freed  from  its  deep  con- 
nections with  the  scalpel,  and  removed  by  disarticulation 
through  the  sacro-coccygeal  joint. 

iii.  Closure  of  wound. — All  bleeding-points  having  been 
arrested  with  silk  ligatures  No.  2,  the  wound  is  closed  with 
silkworm-gut  passed  deep  to  the  raw  surface. 

Danger. — At  times  the  bleeding  from  the  middle  sacral 
artery  is  very  smart,  and  if  the  end  of  the  vessel,  as  it 


i26  GYNECOLOGICAL  SURGERY 

may  be,  is  difficult  to  secure,  a  little  piece  of  the  sacrum 
must  be*  chipped  away,  when  the  artery,  which  is  more 
loosely  attached  higher  up,  can  be  secured. 

Dressing. — A  piece  of  sterilized  gauze,  a  pad  of  wool, 
and  a  T-bandage  must  be  applied. 

After-treatment. — See  Chapter  xxxn.  The  stitches 
are  taken  out  on  the  seventh  day,  and  the  patient  gets  up 
on  the  fourteenth. 


CHAPTER    VII 
OPERATIONS    ON    THE    VAGINA 

ATRESIA    OF    THE    VAGINA 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  scalpel,  scissors,  bladder- 
sound,  dissecting  forceps,  six  pairs  of  long  pressure-forceps, 
four  half -circle  needles  No.  9,  silk  No.  2. 

There  are  various  degrees  of  atresia  of  the  vagina, 
and  three  types  may  be  taken  : 

1.  Where  there  is  simply  a  transverse  septum  across 

the  vagina  in  some  part  of  its  course. 

2.  Where  the  vaginal  canal  in  some  part  of  its  course 

is  absent. 

3.  Where  there  is  no  vagina. 

In  these  conditions  an  operation  may  be  indicated 
for  retained  menstrual  fluid  or  to  render  the  patient 
nubile. 

With  these  malformations  it  will  also  be  convenient  to 
consider  the  operative  treatment  of  hsematometra. 

1.  Transverse  Septum  of  the  Vagina 

In  most  cases  of  so-called  "  imperforate  hymen  "  in  which 
the  menstrual  fluid  is  retained,  if  a  careful  examination 
be  made  the  condition  will  be  found  to  be  due  to  a  trans- 
verse septum  of  the  vaginal  orifice,  the  perforate  hymen 
being  stretched  over  the  swelling  that  is  presenting  at 
the  vaginal  orifice.  In  other  cases  the  septum  may  be 
higher  up  the  canal.  Some  of  these  are  perforated  by  a 
circular  hole  like  a  diaphragm. 

Operation. — The  operation,  if  the  septum  is  complete, 
is  similar  to  that  for   imperforate    hymen  (p.  94).      If  the 

127 


128  GYNECOLOGICAL  SURGERY 

septum  is  perforate,  but  is  the  cause  of  marital  difficulty, 
it  should  be  dissected  away. 

Complications. — As  during  the  patient's  convalescence 
the  cut  septum  may  unite,  rendering  the  operation  useless, 
after  the  fluid  has  escaped  the  vaginal  septum  should  be 
dissected  away.  Any  oozing  from  its  cut  surface  can  be 
controlled  by  a  silk  suture  uniting  the  edges  of  the  septum. 

2.  Absence  of  the  Vagina  in  some  Part  of  its  Course 

Operation. — A  sound  is  passed  into  the  bladder  and 
held  by  the  assistant. 

The  operator,  having  introduced  the  index  finger  of 
his  left  hand  into  the  rectum,  so  that  it,  together  with  the 
sound  in  the  bladder,  may  act  as  a  guide,  makes  a  trans- 
verse incision  in  the  position  of  what  should  be  the  vaginal 
orifice,  and  then  with  the  index  finger  of  his  left  hand,  and 
scissors  if  necessary,  gradually  enlarges  the  wound  in  an 
upward  direction,  taking  care  to  avoid  the  rectum  and 
the  bladder,  until  the  vaginal  canal  is  reached,  when  the 
retained  fluid  is  allowed  to  escape  with  the  same  precautions 
as  are  observed  in  the  operation  for  imperforate  hymen 
(p.  94). 

The  further  steps  of  the  operation  depend  on  the  length 
of  the  wound,  but  if  possible  the  skin  at  the  orifice  should 
be  dissected  free  all  round,  and  then  sutured  to  the  mucous 
membrane  of  the  vagina  so  that  the  raw  surface  is  covered. 

Dangers. — The  patient  is  subject  to  the  same  dangers 
as  are  mentioned  at  p.  95,  and  they  must  be  dealt  with 
in  the  same  way. 

In  addition,  a  careless  operator  might  wound  the 
bladder  or  rectum  ;  and  lastly,  if  the  raw  surface  has  not 
been  covered  with  skin,  the  wound  is  very  likely  gradually 
to  contract,  so  that  in  a  few  months  the  patient  is  in 
practically  the  same  state  as  before. 

After  the  menstrual  fluid  is  evacuated,  therefore,  the 
wound  is  plugged  with  gauze. 

Dressing  and  after-treatment. — Tor  the   general  after- 


ATRESIA  OF  VAGINA  129 

treatment  in  these  two  operations,  see  Chapter  xxxn.  The 
day  following  the  operation  the  gauze  is  taken  out,  the 
newly  formed  vaginal  canal  is  kept  patent  with  a  plug  of 
lint,  and  a  few  days  later  a  perforated  glass  tube,  specially 
made  for  the  purpose,  is  substituted.  In  the  case  where 
a  septum  has  been  divided,  the  patient  gets  up  when  the 
discharge  ceases.  For  the  second  condition  no  definite 
time  can  be  laid  down,  but  it  is  important  to  remember 
that  the  patient  when  convalescent  will  have  to  wear 
a  glass  dilator  for  some  hours  a  day  for  many  months, 
and  perhaps  even  longer.  If  the  use  of  the  dilator  is 
omitted,  through  carelessness,  there  is  the  greatest  risk 
of  the  canal  closing,  and  cases  are  on  record  where  the 
same  patient  has  been  operated  upon  for  this  condition 
over  a  dozen  times. 

In  intractable  cases  the  question  of  hysterectomy  has 
to  be  carefully  considered. 

3.  Total  Absence  of  the  Vagina 

If  by  rectal  examination  it  is  ascertained  that  the 
vagina  is  absent,  a  plastic  operation,  on  the  score  either  of 
nubility  or  of  haematometra,  is,  in  our  opinion,  useless ; 
but  if  at  the  patient's  urgent  solicitation  such  an  opera- 
tion is  attempted,  the  procedure  to  be  followed  is  similar 
to  that  described  at  p.  128,  and  differs  only  in  that  it  is 
more  extensive. 

Dangers. — The  dangers  are  similar  to  those  described 
at  p.  95,  but  in  this  case  it  must  be  remembered  that  the 
new  vagina  is  almost  certain  to  contract,  and  in  most  cases 
so  much  so  as  to  render  the  operation  useless.* 

Operation  for  Haematometra 

When  the  vagina  is  absent,  or  nearly  so,  and  the  uterus 
is  functionally  active  and  dilated  with  retained  menstrual 

*  J.  F.  Baldwin  {Journ.  Amer.  Med.  Assoc,  1910,  iv.  1362)  has  successfully 
constructed  an  artificial  vagina  on  four  occasions  by  resecting  a  portion  of 
the  ileum  and  implanting  it  between  the  bladder  and  the  rectum. 

J 


i3o  GYNECOLOGICAL   SURGERY 

fluid,  the  best  and  proper  operation  is  total  hysterectomy. 
The  Fallopian  tubes  should  be  removed  with  the  uterus, 
as  they  also  are  distended  with  retained  blood,  but  the 
ovaries,  unless  diseased,  must  on  no  account  be  removed. 
As  has  been  indicated,  the  operation  of  making  a  vagina 
when  none,  or  virtually  none,  exists  is  most  unsatis- 
factory, practically  all  the  cases  reverting  to  their  former 
state,  and  having  to  submit  to  further  operative  measures. 
Some  operators  have  indicated  oophorectomy  as  being  the 
best  treatment  if  the  blood  can  be  evacuated  from  below. 
There  is,  however,  no  sense  in  sacrificing  healthy  genital 
glands  for  the  sake  of  a  deformed  and  useless  uterus  ; 
moreover,  there  is  at  least  one  case  on  record  where  this 
operation  was  essayed  and  the  girl  continued  to  menstruate 
because  a  small  piece  of  ovary  had  been  left  behind.  In 
many  cases  it  would  be  difficult  if  not  impossible  to 
avoid  this  owing  to  salpingitis  and  severe  matting  of 
the   ovary   and  Fallopian  tube. 

H^MATOMETRA   OF   AN    UNDEVELOPED    HORN 

This  rare  condition,  occasionally  met  with,  requires 
operative  treatment.  The  distended  horn  lies  close  against 
the  unicorn  uterus,  of  which  it  forms  the  outer  half,  and 
may  be  mistaken  for  a  blood-cyst  of  the  broad  ligament 
if  the  relation  of  the  round  ligament  to  the  tumour  is  not 
observed. 

It  is  usually  possible  to  remove  it,  leaving  the  functional 
half  of  the  uterus  intact,  by  an  operation  similar  to  that  of 
salpingectomy  (p.  497). 

LONGITUDINAL    VAGINAL    SEPTA 

A  septum  of  the  vagina  may  be  longitudinal,  and  when 
complete  produces  a  double  vagina. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  vaginal  retractor,  scalpel, 
six  pairs  of  pressure-forceps,  dissecting  forceps,  four  half- 
circle  needles  No.   o,  silk  No.   2. 


VAGINISMUS  131 

Operation. — The  septum  should  be  dissected  away  and 
the  raw  edges  joined  with  sutures,  after  which  a  piece  of 
sterile  gauze  should  be  left  in  the  vagina. 

Dressing  and  after  -  treatment. — See  Chapter  xxxn. 
The  patient  gets  up  on  the  tenth  day. 

VAGINISMUS 

Certain  cases  of  vaginismus  are  much  improved  by 
enlarging  the  vaginal  orifice. 

The  operations  devised  to  this  end  consist  of  (1)  stretch- 
ing the  vulval  orifice  ;    (2)  Fenton's  plastic  operation. 

1.  Stretching  the  Orifice 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  Sims'  glass  dilators. 

Operation. — The  orifice  can  be  stretched  by  placing 
the  thumbs  or  index  fingers  just  within  the  vagina  and 
forcibly  abducting  them  until  the  fibres  of  the  sphincter 
have  been  lacerated  ;  or  Sims'  glass  dilators  can  be  inserted, 
commencing  with  a  small  size  and  gradually  increasing 
the  size  until  the  desired  effect  is  obtained. 

After  the  operation  is  completed,  a  dilator  somewhat 
smaller  than  the  largest  size  passed,  but  sufficiently  large 
to  stretch  the  orifice,  is  inserted  and  allowed  to  remain  in 
position  until  the  patient  is  well  recovered  from  the  anaes- 
thetic and  complains  of  its  presence. 

Dressing  and  after-treatment. — See  Chapter  xxxn. 
The  patient  can  get  up  the  day  after  the  operation. 

The  glass  vaginal  dilator  should  be  worn  night  and 
morning  for  one  hour  until  the  tendency  of  the  orifice 
to  contract  spasmodically  disappears.  If  the  patient  has 
any  difficulty  in  introducing  the  dilator,  which  should  be 
well  lubricated,  some  5  per  cent,  cocaine  ointment  can 
be  applied  at  the  vaginal  orifice  for  a  few  minutes  before 
its  insertion ;  and  if  the  dilator  left  in  after  the  operation 
causes  much  distress  on  being  passed,  a  smaller  size  can 
be  used  at  first. 


^ 


GYNECOLOGICAL  SURGERY 


2.  Plastic  Enlargement  of  the  Vaginal  Orifice 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — -Clover's  crutch,  scissors  and  scalpel,  four 
pairs  of  pressure-forceps,  dissecting  forceps,  four  curved 
needles  No.  7,  silkworm-gut. 

Operation. — The    mucous    membrane    on  the  posterior 


vy 


Fig.   73. — Plastic  enlargement 
of    the    vulval     orifice  :      Re- 
flecting  the  vaginal  flap. 


wall  having  been  dissected  up  as  a  flap  (Fig.  73),  the  peri- 
neum is  incised  half-way  down  to  the  anus,  the  cut  being 
in  the  long  axis  of  the  vagina.  The  wound  then  gapes, 
and  a  raw  surface  more  or  less  diamond-shaped  is  formed 

(Fig.  74)- 

Sutures  of  silkworm-gut  are  now  inserted  so  as  to  affix 
the  cut  edge  of  the  flap  of  mucous  membrane  to  the  cut 


VAGINISMUS 


i33 


skin-edges  (Figs.  75  and  76),  the  upper  and  lower  angles 
of  the  wound  are  approximated,  and  the  resulting  scar  is 
transverse  to  the  long  axis  of  the  vagina. 

Another  and  simpler  method  of  performing  this  opera- 
tion is  to  make  a  longitudinal  median  incision  through  the 
skin    and    mucous    membrane,    stretch    the    wound    till    it 


Fig.  74. — Incising  the 
perineum. 


becomes  diamond-shaped,  and  then  suture  it  up  so  that 
the  upper  angle  of  the  diamond  is  approximated  to  the 
lower  angle,  and  the  suture  line  when  finished  is  transverse 
to  the  vagina. 

Dressing  and  after-treatment. — For  the  general  lines, 
see  Chapter  xxxn.  The  stitches  are  removed  on  the 
seventh  day. 


134 


GYNECOLOGICAL  SURGERY 


ig.    75. — Suturing   the   vaginal 
flap  to  the  skin. 


Fig.  76. — The  operation  completed. 


VAGINAL  MYOMA 


i35 


MYOMA    OF    THE    VAGINA 

Preparation  of  the  patient. — See  pp.  78-82. 
Instruments. — Clover's  crutch,  Auvard's  speculum,  vagi- 
nal retractor,  bladder-sound,   scalpel,  scissors,  six  pairs  of 


Fig.    77. — Vaginal    my- 
oma :    Incising  the  cap- 
sule of  the   tumour. 


long  pressure-forceps,  dissecting  forceps,  four  half-circle 
needles  No.  7,  silk  No.  2. 

Operation. — The  method  to  be  chosen  depends  upon 
whether  the  tumour  is  pedunculated  or  sessile. 

Pedunculated  myoma. — The  mucous  membrane  cover- 
ing the  pedicle  at  its  junction  with  the  tumour  should  be 
incised  and  reflected  and  the  tumour  shelled  out. 

The   pedicle  is  then    ligated  with    mattress-sutures   of 


136 


GYNECOLOGICAL  SURGERY 


silk  to  check  haemorrhage,  and  the  mucous  membrane  over 
it  is  brought  together  with  a  few  interrupted  sutures. 

Sessile  myoma. — The  sound  is  passed  into  the  bladder 
or  the  index-finger  into  the  rectum,  according  to  whether 
the  tumour  is  on  the  anterior  or  posterior  vaginal  wall, 
in  order  to  ascertain  the  relation  of  these  organs  to  the 
tumour. 


Fig.  78. — Enucleation  of 
the  tumour. 


The  mucous  membrane  covering  the  tumour,  together 
with  the  capsule,  is  then  incised  (Fig.  77),  and  the  tumour 
is  easily  enucleated  with  the  finger  or  scissors  (Fig.  j8). 
Any  bleeding  is  controlled  by  the  silk  sutures  which  unite 
the  edges  of  the  mucous  membrane,  and  which  should  be 
passed  deep  to  the  raw  surface  left  after  the  enucleation 
of  the  tumour.  If  any  spurting  vessels  can  be  seen,  these 
may  be  ligated  in  the  usual  way  before  the  wound  is  sutured. 


VAGINAL  CYSTS  *37 

Dangers. — The  bladder,  ureters,  or  rectum  may  be 
wounded  during  the  enucleation. 

Dressing  and  after-treatment. — See  Chapter  xxxil.  The 
patient  gets  up  in  a  fortnight. 

VAGINAL    CYSTS 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Auvard's  speculum,  vaginal  retractor, 
Clover's  crutch,  scalpel,  scissors,  dissecting  forceps,  six 
pairs  of  long  pressure-forceps,  four  half-circle  needles 
No.  7,  silk  No.  2. 

Operation. — Auvard's  speculum  is  inserted  into  the 
vagina  if  the  cyst  is  on  the  anterior  wall,  or  a  vaginal 
retractor  is  held  in  position  against  the  anterior  vaginal 
wall  by  an  assistant  if  the  cyst  is  on  the  posterior 
wall. 

The  mucous  membrane  covering  the  cyst  is  seized  with 
rat-toothed  dissecting  forceps  and  carefully  incised  till 
the  cyst-wall  is  exposed.  The  cyst  is  enucleated  with  the 
index-finger  or  handle  of  the  scalpel.  The  excess  of  mucous 
membrane  covering  the  cyst  is  cut  away,  any  oozing  is 
stopped,  and  the  wound  united  with  a  silk  suture  No.  2. 

Complications. — With  the  primary  incision  or  during 
the  enucleation  the  cyst  may  burst.  The  cyst-wall  may 
then  be  very  difficult  to  remove. 

Dangers. — With  large  cysts  there  is  a  danger  of  wound- 
ing the  ureter,  bladder,  or  rectum,  and  the  bleeding  may 
be  serious.  In  these  cases,  therefore,  it  may  be  safer 
either  to  open  the  cyst,  plug  it  with  gauze,  and  let  it  heal 
by  granulation,  or  remove  only  that  piece  of  the  cyst- 
wall,  together  with  the  mucous  membrane  covering  it, 
which  projects  towards  the  vaginal  canal.  The  edge  of 
the  cyst-wall  can  then  be  sutured  to  that  of  the  mucous 
membrane,  the  remainder  of  the  cavity  being  plugged 
with  gauze  and  allowed  to  granulate  up. 

Dressing  and  after-treatment. — See  Chapter  xxxn.  The 
patient  gets  up  in  about  a  fortnight. 


i38  GYNECOLOGICAL  SURGERY 

PARTIAL    VAGINECTOMY    FOR    MALIGNANT 
DISEASE    OF    THE    VAGINA 

The  vagina  may  be  the  seat  of  sarcoma  in  early  life, 
and  of  carcinoma  at  a  later  period. 

As  a  rule,  the  patients  apply  for  relief  too  late  for  any 
operative  measures  of  a  radical  nature  to  be  undertaken, 
and  any  palliative  measures,  such  as  scraping  and  cauter- 
izing the  growth,  may  only  make  matters  worse  by  causing 
a  fistula  earlier  than  would  otherwise  have  occurred. 
If  the  patient  is  seen  at  an  early  stage  of  the  disease  and 
the  growth  is  situated  close  to  the  outlet,  it  may  be  removed 
by  partial  vaginectomy. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  vaginal  retractor,  scalpel, 
bladder-sound,  six  pairs  of  long  pressure-forceps,  dissecting 
forceps,   four  half-circle  No.   7  needles,   silk  No.   2. 

Operation.  —  The  relation  of  the  bladder  and  rectum 
having  been  ascertained,  the  speculum  is  inserted  so  as 
to  expose  the  growth,  which  is  then  steadied  with  forceps. 
The  mucous  membrane  having  been  incised  all  round 
and  well  clear  of  the  growth,  the  latter  is  separated  by 
scissors  or  scalpel.  Any  oozing  can  usually  be  stopped 
by  sutures  passed  through  the  raw  surface  ;  if  not,  the 
bleeding-points  must  be  ligatured.  When  the  bleeding 
has  ceased,  the  mucous  membrane  is  sutured  with  No.  2 
silk  sutures. 

Difficulties. — If  the  disease  occurs  in  an  elderly  woman 
the  vaginal  canal  may  have  atrophied,  and  in  this  case  it 
may  be  a  difficult  matter  to  get  at  the  growth  properly. 
If  so,  a  paravaginal  section  (p.  295)  will  be  found  of  great 
service. 

Dangers. — If  the  growth  is  on  the  anterior  wall  the 
bladder  may  be  injured  during  its  removal,  and  the  rectum 
may  be  injured  when  the  growth  is  being  removed  from 
the  posterior  wall. 

Alternative  method. — H   the   growth   is  extensive,  and 


ANTERIOR  GOLPORRHAPHY  139 

is  not  limited  to  the  first  inch  of  the  vagina,  a  hystero- 
vaginectomy  is  the  best  treatment  (see  p.  261). 

Dressing  and  after  -  treatment. — See  Chapter  xxxn. 
The  patient  gets  up  in  a  fortnight. 

ANTERIOR    COLPORRHAPHY 

Indications. — -This  operation  is  performed  for  the 
relief  of  cystocele  or  prolapse  of  the  anterior  vaginal  wall, 
and  consists  in  removing  a  portion  of  the  mucous  membrane 
of  the  anterior  vaginal  wall,  and  so  narrowing  the  canal. 
In  the  hands  of  many'  surgeons  this  operation  does  not 
appear  to  be  very  successful  in  its  ultimate  object,  and 
on  this  account  it  has  of  late  years  gone  out  of  fashion. 
Many  failures,  however,  may  be  fairly  attributed  to  in- 
sufficient tissue  being  removed.  In  our  opinion,  the  slighter 
cases  of  protrusion  of  the  anterior  vaginal  wall  are  suffi- 
ciently relieved  by  an  efficient  perineoplasty  ;  in  the  more 
severe  cases,  with  great  redundancy  of  the  anterior  vaginal 
wall,  this  remedy  is  insufficient,  and  an  anterior  colpor- 
rhaphy  should  be  performed  in  addition. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  Auvard's  speculum,  scal- 
pel, six  pairs  of  pressure-forceps,  rat-toothed  dissecting 
forceps,  bladder  -  sound,  volsella,  curved  needles  No.  7, 
silk  No.  2. 

Operation. — The  speculum  having  been  inserted  in 
the  vaginal  canal,  the  cervix  is  pulled  down  with  the 
volsella.  The  anterior  vaginal  wall  is  now  put  on  the 
stretch  by  four  pairs  of  pressure-forceps,  one  applied  just 
behind  the  urethral  orifice,  a  second  at  the  junction  of 
the  vaginal  vault  with  the  cervix,  while  the  third  and 
fourth  are  applied  laterally  opposite  each  other.  Exactly 
how  far  apart  the  lateral  forceps  are  to  be  fixed  depends 
on  the  amount  of  redundant  tissue,  and  can  best  be  esti- 
mated by  altering  their  position  until,  when  they  are 
drawn  together,  the  cystocele  is  obliterated. 

i.  Demarcation    of    flap    and    removal. — The     mucous 


140 


GYNAECOLOGICAL  SURGERY 


membrane  being  stretched  by  traction  on  the  forceps,  an 
incision  is  made  with  a  scalpel,  between  each  pair  of  forceps, 
through  the  mucous  membrane,  so  that  a  diamond-shaped 
piece  of  tissue  is  delineated  (Fig.  79).  This  piece  of  mucous 
membrane   is   then   very   carefully  dissected   off   from   the 


Fig.  79. — Anterior  colporrhaphy  :    Demarcation  of 
the  area  to  be  denuded. 

base  of  the  bladder  (Fig.  80)  by  means  of  the  scalpel  and 
fingers,  the  latter  in  some  cases  being  quite  sufficient. 

Any  oozing  will  usually  stop  after  the  application  of 
pressure-forceps  or  on  suturing  the  wound  ;  in  some  cases 
the  bleeding  is  rather  more  than  can  be  arrested  by  these 
means,  and  it  should  then  be  controlled  by  the  application 
of  ligatures. 


ANTERIOR    GOLPORRHAPHY 


141 


ii.  Obliteration  of  the  denuded  area.  —  Interrupted 
sutures  of  silk  are  passed  with  a  half-circle  needle,  com- 
mencing at  the  right  external  angle  of  the  wound  and 
continuing  transversely  across  the  vaginal  wall,  to  terminate 
at  the  left  external  angle  (Fig.  81),  so  that  the  scar  lies 
transversely  to  the  vaginal  axis. 


Fig.  80. — Denudation  of  the  demarcated  area. 


Dangers. — Care  must  be  taken  when  dissecting  off  the 
mucous  membrane  not  to  injure  the  bladder.  If  the  scalpel 
is  being  used,  this  can  be  avoided  by  keeping  the  cutting 
edge  towards  the  flap  and  away  from  the  bladder  ;  also 
by  passing  the  sound  into  the  bladder  from  time  to  time, 
and  so  estimating  the  amount  of  intervening  tissue. 


142 


GYNECOLOGICAL  SURGERY 


Dressing  and  after-treatment. — For  the  general  lines 
of  after-treatment,  see  Chapter  xxxn.  The  patient  may 
get  up  on  the  twenty-first  day.  She  should  be  careful  for 
some  months  following  the  operation  not  to  follow  any 
occupation  which  causes  straining,  as  until  the  parts  have 


Fig.  81. — Suture  of  the  wound. 

thoroughly  contracted  up    there   is  danger  of  the  vaginal 
wall  again  becoming  stretched. 

POSTERIOR    COLPORRHAPHY 

Indications. — This  operation,  which  removes  a  portion 
of  the  mucous  membrane  from  the  posterior  vaginal  wall, 
is  indicated  in  cases  of  rectocele  and  prolapse  of  the  posterior 
vaginal  wall.  It  is  best  performed  in  combination  with 
perineoplasty,  and  the  operation  of  posterior  colporrhaphy 
in  these  circumstances  is  the  same  as  that  of  perineoplasty, 
except    that  a    much  larger    piece    of    mucous  membrane 


POSTERIOR  GOLPORRHAPHY 


i43 


must  be   removed,  and  therefore    a   larger   flap  will   have 
to  be  dissected  up. 

In  some  cases  of  rectocele  the  protrusion  of  the  posterior 
vaginal  wall  is  limited  to  its  upper  part  only,  in  which 
case  the  operation  now  to  be  described  will  suffice. 


Fig.  82. — Posterior  colpor- 
rhaphy  :  Demarcation  of 
the  area  to  be  denuded. 


Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — -As  for  anterior  colporrhaphy  (p.  139). 

Operation,  i.  Demarcation  of  the  flap. — With  a  pair 
of  forceps  the  lowermost  portion  of  the  bulging  vaginal 
mucous  membrane  is  seized  and  the  rectocele  is  with- 
drawn to  its  full  extent.  The  mucous  membrane  being 
now  drawn  taut,  a  diamond-shaped  incision  is  made 
(Fig.  82),  and  a  piece  of  mucous  membrane  is  dissected 
off  (Fig.  83). 

ii.  Obliteration  of  the  raw  surface. — The  raw  surface 
is  obliterated  by  running  a  continuous  suture  of  silk 
from   the   right   lateral   angle   of  the   incision   to   the   left 


i44 


GYNAECOLOGICAL  SURGERY 


(Fig.   84),   so  that  the  resulting  scar  lies  transversely  to 
the  direction  of  the  vagina. 

Dressing  and  after-treatment. — See  Chapter  xxxn.  The 
patient  may  get  up  on  the  twenty-first  day. 


g.  83. — Denudation  of  the 
demarcated  area. 


URETHRO-VAGINAL    FISTULA 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  Auvard's  speculum,  scis- 
sors, scalpel,  dissecting  forceps,  bladder-sound,  four  pairs 
of  pressure-forceps,  four  curved  needles  No.  n,  silk  No.  1. 

Operation. — A  bladder-sound  having  been  introduced 
into  the  urethra,  the  vaginal  mucous  membrane  in  the 
neighbourhood   of   the   fistula   for   about   half   an   inch   is 


VESICOVAGINAL  FISTULA 


i45 


dissected  off.  As  many  interrupted  sutures  of  silk  as  may 
be  necessary  are  passed  deeply  to  the  raw  surface. 

When  the  sutures  are  tied  the  fistulous  opening  is 
entirely  obliterated. 

Dressing  and  after-treatment. — See  Chapter  xxxii.  The 
patient  gets  up  on  the  fourteenth  day. 


Fig.  84.— Suture  of  the 

wound  in  posterior  col- 

porrhaphy. 


VESICOVAGINAL    FISTULA 

A   vesico-vaginal  fistula  may   be   closed   by   paring  or 
flap-splitting,  performed  through  the  vagina. 

Preparation  of  the  patient. — In  addition  to  the  prepara- 
tion mentioned  at  pp.  78-82,  the  surgeon  must  be  sure 
that  there  is  no  cystitis  and  that  the  bladder,  except  for 
the  fistula,  is  in  a  healthy  condition.  If  cystitis  is  present, 
this  must  first  be  cured  by  appropriate  treatment,  for 
the  chances  of  the  operation-wound  uniting  if  the  urine 
is  already  septic  are  remote. 
K 


146  GYN/ECOLOGICAL  SURGERY 

Instruments. — Clover's  crutch,  Auvard's  speculum, 
vaginal  retractors,  scalpel,  dissecting  forceps,  six  pairs  of 
long  pressure-forceps,  four  half-circle  needles  No.  n,  shot, 
coil,  shot  compressors,  silkworm -gut,  silk  No.   1. 

1.  Operation  by  paring. — Auvard's  speculum  is  inserted 
into  the  vagina,  which  is  then  thoroughly  douched  with 
hot  water,  and  the  bladder  by  means  of  a  catheter  in  the 
urethra  is  also  freely  washed  out  through  the  fistula. 

i.  Excision  of  vaginal  mucous  membrane  in  the  region  of 
the  fistula. — The  vaginal  wall  in  the  neighbourhood  of  the 
fistula  having  been  steadied  with  pressure-forceps,  an  incision 
is  made  with  a  sharp  scalpel  in  the  mucous  membrane  of 
the  anterior  vaginal  wall  surrounding  the  fistula  and  about 
half  an  inch  from  its  edge,  by  which  means  the  amount 
of  mucous  membrane  to  be  removed  is  delineated.  The 
strip  of  mucous  membrane  thus  determined  is  then  care- 
fully dissected  off  the  bladder,  leaving  an  oozing  raw 
surface. 

ii.  Insertion  of  sutures. — Thin  silkworm-gut  sutures  are 
now  inserted.  The  needle  is  entered  through  the  vaginal 
mucous  membrane  just  externally  to  the  raw  area,  and 
is  kept  deep  to  the  raw  surface  and  brought  out  at  one 
edge  of  the  fistula.  The  needle  is  then  re-inserted  in  the 
opposite  edge  of  the  fistula,  kept  deep  to  the  raw  surface 
on  that  side,  and  brought  out  through  the  mucous  membrane 
of  the  vagina  clear  of  the  raw  area.  After  a  sufficient 
number  of  sutures  have  been  passed,  the  bladder  is  care- 
fully washed  out  with  warm  boric  solution,  which  is  passed 
by  means  of  a  catheter  through  the  urethra,  and  escapes, 
together  with  any  blood-clots,  into  the  vagina  through  the 
fistulous  opening,  and  the  fistula  is  then  closed  by  approxi- 
mating the  sutures  with  shot  and  coil  so  that  the  raw  areas 
on  each  side  are  closely  in  contact.  The  sutures  may  be 
applied  from  side  to  side,  or  from  above  downwards, 
according  to  whether  the  edges  of  the  fistula  approximate 
more  exactly  in  one  direction  or  the  other. 

Difficulties. — On  account   of   the  cicatricial  contraction 


VESICOVAGINAL  FISTULA  147 

of  the  tissue  in  the  neighbourhood  of  the  fistula,  it  may 
be  impossible  to  bring  the  edges  of  the  opening  together, 
or,  having  done  so,  it  may  be  found  that  the  tension  on 
the  stitches  is  so  great  that  the  sutures  will  probably  cut 
out.  In  these  circumstances  the  cicatricial  tissue  in  the 
neighbourhood  of  the  fistula  may  be  divided  first,  by 
incising  it  in  a  direction  parallel  with  the  long  axis  of  the 
vagina  on  either  side,  thus  freeing  the  edges  of  the  fistula, 
after  which  it  is  closed  in  the  manner  already  described. 
The  wounds  in  the  vaginal  mucous  membrane  made  to 
relieve  tension  are  then  closed  with  sutures,  so  that  the 
direction  of  the  incision  will  eventually  be  at  right  angles 
to  the  long  axis  of  the  vagina. 

Dangers. — In  removing  the  strip  of  mucous  membrane 
from  the  anterior  vaginal  wall  the  mucous  membrane  of 
the  bladder  may  be  injured,  in  which  case  the  rather  free 
oozing  may  be  difficult  to  arrest.  Irrigation  with  hot 
water,  and  the  application  of  sutures  if  this  is  unsuccessful, 
may  be  necessary.  If  any  portion  of  the  mucous  membrane 
of  the  bladder  becomes  tucked  into  the  wound  when  the 
sutures  for  closing  the  fistula  are  tied,  healing  will  not  be 
complete  and  a  small  fistulous  track  may  remain.  If  the 
fistula  is  near  the  neck  of  the  bladder,  care  will  have  to  be 
exercised  in  preparing  the  raw  surface  round  the  opening, 
and  also,  when  passing  the  sutures,  that  the  ureters  are 
not  injured. 

Lastly,  at  times,  after  the  operation  is  completed  there 
is  rather  free  oozing  of  blood  into  the  bladder.  If  this  takes 
place,  the  bladder  must  be  thoroughly  irrigated  every 
hour  or  two  with  hot  boric  solution  containing  adrenalin 
(1 — 1,000)  through  a  double  -  channelled  catheter,  so  as 
to  prevent  the  clot  from  distending  the  bladder  and  so 
interfering  with  the  sutures. 

Dressing. — A  gauze  drain  is  inserted  into  the  vagina 
and  a  self-retaining  catheter  left  in  the  bladder. 

After-treatment. — For  the  general  lines,  see  Chapter 
xxxii.      On    the    day   following    the    operation    the    gauze 


148 


GYNAECOLOGICAL  SURGERY 


is  removed,  after  which  the  vagina  is  douched  twice  daily 
with  biniodide  of  mercury,  1 — 4,000. 

The  sutures  are  removed  in  fourteen  days,  and  the 
patient  gets  up  at  the  end  of  three  weeks. 

The  bladder  should  be  continuously  catheterized  for  a 
week,  after  which  it  should  be  emptied  every  two  hours 
for  the  next  two  or  three  days,  and  then  at  progressively 
increasing  intervals.     Most  particular  care  must  be  taken 


Fig.  85. — Vesico-vaginal 

fistula  :    Demarcation  of 

the  flap. 


that  the  bladder  is  not  infected  during  the  necessary 
manipulations.  At  the  end  of  three  weeks  the  patient 
may  be  permitted  to  pass  urine  naturally.  Urotropine  in 
5-grain  doses  should  be  given  three  times  daily  during 
the  whole  of  the  convalescence  from  the  operation. 

2.  Operation  by  flap-splitting. — This  is  a  more  elabo- 
rate but  better  operation,  especially  in  cases  where  the 
defect  is  large.  Its  exact  technique  will  require  to  be 
varied  according  to  the  position  and  size  of  the  fistula. 
The  steps  are  commonly  as  follows  : — 


VESICO-VAGINAL  FISTULA 


149 


i.  Resecting  the  fistulous  opening. — The  mucous  mem- 
brane of  the  anterior  vaginal  wall  half  an  inch  from  the 
neighbourhood  of  the  opening  into  the  bladder  is  seized 
with  pressure-forceps,  and  a  horseshoe-shaped  incision 
with  its  base  uppermost  is  then  made  with  a  scalpel  round 
the  opening  and  half  an  inch  from  it  (Fig.  85). 

This   piece    of   mucous   membrane,    delineated   by   the 


Fig.  86. — Dissection 
of  the  flap. 


incision  made,  is  dissected  as  a  flap  with  a  scalpel,  and 
the  edges  of  the  opening  are  well  undermined  so  as  to 
separate  the  vaginal  wall  from  the  bladder  base,  which 
is  now  exposed   (Fig.   86). 

ii.  Suturing  the  hole  in  the  bladder. — A  purse-string 
suture  of  No.  1  silk  is  passed  through  the  muscular  coat  of 
the  bladder  base  and  round  the  hole  in  the  bladder,  about 
a  quarter  of  an  inch  from  it,  so  that  when  the  suture  is  tied 
the  hole  is  closed  and  the  edge  is  inverted  into  the  bladder 
(Fig.  87).     If  the  hole  is  too  large  for  a  purse-string  suture, 


i5o 


GYNECOLOGICAL  SURGERY 


it   must   be   closed    by   interrupted   sutures,   but  in  either 
case  the  silk  should  not  penetrate  the  mucous  membrane. 

iii.  Preparing  the  flap  of  vaginal  mucous  membrane. — 
The  flap  of  vaginal  mucous  membrane  which  has  been 
reflected  is  now  partly  removed,  the  portion  cut  away 
including  the  opening   of  the  fistula   (Fig.  88). 


Fig.  87. — Closing  the  hole  in  the  bladder. 

iv.  Suturing  the  vaginal  incision. — The  remainder  of 
the  flap  is  pulled  down  and  united  to  the  cut  edges  of  the 
original  incision  with  interrupted  silkworm-gut  sutures, 
which  may  be  fastened  with  shot  and  coil  for  ease  in  sub- 
sequent removal  (Fig.  89). 

After-treatment. — See  Chapter  xxxn.  The  sutures  in 
the  vaginal  mucosa  should  not  be  removed  before  the 
tenth  day,  or  later.  The  treatment  of  the  bladder  is  the 
same  as  that  proper  to  the  last-described  operation. 


VESICOVAGINAL  FISTULA 


151 


Fig.  88. — Preparing  the  vaginal  flap. 


89. — Suturing  the 
vaginal  flap. 


152  GYNAECOLOGICAL  SURGERY 

Alternative    Operations 

In  cases  in  which  closure  by  vaginal  operation  has 
failed,  the  surgeon  has  a  choice  of  two  other  methods.  One 
consists  in  opening  the  abdomen,  separating  the  bladder 
from  the  cervix  and  the  vaginal  wall,  and  suturing  the 
apertures  separately.  The  other  consists  in  closing  the 
upper  part  of  the  vagina  by  a  plastic  operation,  thus 
making  it  an  annexe  of  the  bladder.  Subtotal  hysterec- 
tomy must  also  be  performed  to  arrest  menstruation. 

RECTO-VAGINAL    FISTULA 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  vaginal  retractor,  scalpel, 
scissors,  six  pairs  of  long  pressure-forceps,  dissecting  forceps, 
four  half-circle  needles  No.  11,  shot,  coils,  shot  compressor, 
silkworm-gut,  silk  No.  1. 

Operation. — -The  method  of  treating  this  condition 
depends  on  the  position  of  the  fistulous  opening. 

If  the  fistula  is  near  the  anus,  it  is  best  to  cut  through 
the  perineum  into  the  rectum,  so  that  the  local  condition 
becomes  that  of  complete  rupture  of  the  perineum.  The 
wound  can  then  be  closed  by  the  method  described  at 
p.  117.  If  the  opening  is  high  up  in  the  recto-vaginal 
septum,  its  edges  should  be  freshened  and  the  fistula  then 
closed  with  silkworm-gut  sutures. 

If  the  fistula  occupies  a  position  between  these  two 
extremes,  probably  the  best  result  will  be  obtained  by 
dissecting  up  the  posterior  vaginal  wall  beyond  the  opening 
and  removing  that  portion  which  is  perforated,  then  closing 
the  hole  in  the  rectum  with  separate  sutures  of  silk,  and 
afterwards  suturing  the  cut  edges  of  the  vaginal  mucous 
membrane  in  the  manner  described  in  the  operation  for 
posterior  colporrhaphy  (p.  143). 

Dressing  and  after-treatment.— See  Chapter  xxxn.  The 
patient  may  get  up  in  three  weeks. 


CHAPTER    VIII 
OPERATIONS    ON    THE    CERVIX 

ATRESIA    OF    THE    CERVIX 

This  condition  is  usually  the  result  of  operations  on  the 
cervix,  or  of  the  application  of  strong  caustics  such  as 
nitric  acid.  Haemato-trachelos  is  the  result  if  any  part  of 
the  cervix  remains,  the  uterus  forcing  the  menstrual  blood 
into  the.  cervix  and  distending  it.  Where  the  whole  cervix 
has  been  previously  removed  or  destroyed,  the  body  of 
the  uterus  becomes  distended  together  with  the  Fallopian 
tubes,  and  the  whole  will  require  removal. 

For  haemato-trachelos  the  following  operation  will  be 
sufficient : — ■ 

Preparation  of  the   patient. — See  pp.  78-82. 

Instruments. — Clover's  crutch,  Auvard's  speculum,  vol- 
sellae,  uterine  sound,  Fenton's  dilators,  scalpel,  four  half- 
circle  needles  No.  11,  silk  No.  1. 

Operation. — -Auvard's  speculum  having  been  inserted 
into  the  vagina,  the  cervix  is  seized  with  two  volsellae  and 
drawn  down,  and  an  attempt  may  then  be  made  to  over- 
come the  obstruction  by  passing  a  sound  or  the  smallest 
Fenton's  dilator.  If  this  fails,  the  knife  will  have  to  be 
used  to  make  a  passage.  After  the  fluid  has  been  evacuated, 
the  cervical  canal  should  be  dilated  to  No.  12,  and  its 
mucous  membrane  if  possible  sutured  to  the  vaginal  surface 
of  the  cervix,  after  which  the  canal  is  packed  with  gauze. 

Dangers. — In  long-continued  obstruction  the  Fallopian 
tubes  become  dilated  and  adherent  to  surrounding  structures, 
and  may  rupture  during  the  evacuation  of  the  retained 
blood  and  mucus.  In  such  a  case  it  is  better  to  perform 
salpingo-hysterectomy. 

153 


i54  GYNECOLOGICAL  SURGERY 

Dressing  and  after-treatment. — The  general  lines  of 
after-treatment  are  described  in  Chapter  xxxn.  A  glass 
stem-pessary  should  be  inserted  into  the  cervical  canal, 
and  kept  there  until  the  patient  gets  up,  that  is  in 
about  fourteen  days.  The  vagina  should  be  carefully 
douched  three  times  a  day. 

DILATATION    OF    THE    CERVIX 

Indications. — -This  operation  may  be  indicated  in  cases 
of  dysmenorrhoea  and  sterility,  for  removing  a  myomatous, 
mucous  or  placental  polypus  of  the  uterus,  for  enucleating 
a  submucous  myoma,  as  a  preliminary  to  curetting  the 
uterus,  and  as  a  means  of  diagnosis  in  cases  of  suspected 
cancer  or  other  intra-uterine  disease. 

Preparation   of  the  patient. — See  pp.  78-82. 

Instruments.  —  Clover's  crutch,  Auvard's  speculum, 
uterine  sound,  two  volsellae,  Fenton's  dilators,  one  long 
pair  of  Spencer  Wells  forceps,  one  pair  of  ring  forceps, 
scissors,  two  curved  needles  No.  9,  silk  No.  2. 

Operation. — Before  the  operation  is  begun,  the  patient 
is  examined  bimanually  to  ascertain  the  position  and 
mobility  of  the  uterus  and  the  presence  or  absence  of  any 
disease  of  the  Fallopian  tubes  or  ovaries.  The  speculum 
is  then  inserted  into  the  vaginal  canal  and  a  vaginal  douche 
given,  after  which  the  anterior  lip  of  the  cervix  is  secured 
with  the  volsellse,  the  uterus  is  thus  steadied,  and  the 
sound  is  passed  to  confirm  the  position  of  the  uterus  noticed 
on  bimanual  examination  and  to  ascertain  its  length 
(Fig.  90).  Instead  of  both  volsellae  being  fixed  to  the 
anterior  lip  of  the  cervix,  the  posterior  lip  may  be  seized 
with  the  second  volsella. 

It  is  better  to  use  two  volsella?  than  one,  because  a 
firmer  hold  of  the  cervix  is  secured,  but  in  some  cases 
where  the  cervical  tissue  is  soft,  as  after  a  recent  mis- 
carriage or  labour,  one  volsella  will  probably  be  suffi- 
cient. In  these  cases,  indeed,  it  is  better  if  possible  to 
use  instead   a  ring  forceps   so   as   to   avoid  wounding  the 


DILATATION  OF  CERVIX 


i55 


cervix  and  making  an  additional  channel  for  possible  in- 
fection. 

The   dilators   are   now  taken   from   the   dish   in   which 
they  have  been  previously   arranged  in  order,   dipped  in 


Fig.  90. — Dilatation  of  cervix 
Passing  the  sound. 


glycerinum  acidi  carbolici  (B.P.),  and  pushed  up  the  cer- 
vical canal  ;  the  operator  commencing,  of  course,  with 
the  smallest  instrument,  unless  from  the  appearance  of  the 
os  it  is  obvious  that  the  dilatation  can  be  begun  with  a 
size  larger  than  this. 


i56  GYNECOLOGICAL  SURGERY 

It  is  here  to  be  remarked  that  the  passage  of  a  gradu- 
ated dilator  up  the  uterine  canal  is  a  manoeuvre  least  of 
all  requiring  mere  muscular  force.  The  operator  should 
constantly  have  before  him  a  mental  picture  of  the  shape, 
length,  and  direction  of  the  uterine  canal  as  previously- 
determined  by  his  bimanual  examination  and  the  passage 
of  the  sound.  He  is  thus  enabled  to  control  and  regulate 
the  force  he  is  using  in  accordance  with  the  varying  resist- 
ances the  point  of  the  dilator  encounters  at  different  parts 
of  the  uterine  canal,  and  by  correctly  directing  the  instru- 
ment he  minimizes  these  resistances  as  far  as  is  possible. 
The  dilator  should  be  held  in  the  right  hand,  with  the 
second,  third,  and  fourth  fingers  slightly  extended,  so 
that  if  it  slips,  because  of  a  too  sudden  or  a  too  forcible 
manipulation,  the  finger-tips  will  impinge  on  the  left 
buttock  of  the  patient  before  the  dilator  has  travelled 
any  distance,  and  perforation  of  the  uterine  wall  will  be 
avoided.  While  the  dilator  is  being  passed,  the  operator 
or  his  assistant  should  not  only  hold  the  volsellas  firmly 
with  his  left  hand,  thus  steadying  the  uterus,  but  should 
actually  assist  the  dilatation  by  pulling  the  cervix  over 
the  dilator  (Fig.  91). 

The  amount  of  force  to  use  in  passing  the  dilator  will 
depend  on  the  condition  of  the  cervix,  and  such  know- 
ledge can  only  be  gained  by  practical  experience.  But 
nothing  approaching  the  full  force  the  ODerator  is  capable 
of  using  is  ever  justifiable. 

There  are  various  types  of  screw  dilators  on  the  market, 
but,  in  our  opinion,  they  are  much  inferior  to  the  graduated 
instruments,  and  of  these  Fenton's  dilators  are  the  most 
suitable  we  know  of  for  the  purpose  under  discussion. 
When  the  operator  judges  that  the  particular  dilator  he 
is  using  has  been  in  position  for  a  sufficient  length  of  time, 
he  directs  his  assistant  to  extract  it,  whilst  he  himself  has 
the  next  largest  dilator  ready,  so  that  it  can  be  introduced 
at  once,  before  the  internal  os  has  time  to  contract. 

Amount   of  dilatation. — The   amount   of   dilatation  will 


DILATATION  OF  CERVIX 


i57 


vary  with  the  object  in  view.  When  used  for  sterility, 
dysmenorrhoea,  or  as  a  preliminary  to  curettage  of  the 
uterus,  a  dilatation  up  to  No.  12  Fenton  will  be  found 
sufficient.  For  conditions,  however,  which  require  the 
introduction  of  a  finger,  such  as  the  removal  of  retained 


Fig.  91. — Passing  the  dilators. 

products  of  conception,  the  digital  exploration  of  the 
cavity  of  the  uterus,  or  the  removal  of  small  submucous 
myomata,  the  dilatation  must  be  carried  to  No.  18.  !#.  krl 

Conclusion  of  the  operation. — If  the  object  of  the 
operation  is  the  cure  of  dysmenorrhoea,  no  further  steps 
are  usually  taken  beyond  the  dilatation  already  described. 

Some  operators,  with  a  view  to  make  more  permanent 


i5»  GYNECOLOGICAL  SURGERY 

the  enlargement  of  the  canal,  insert  a  glass  stem-pessary 
into  the  uterus  for  a  week  or  ten  days.  We  do  not  do  this, 
and  we  choose  the  day  or  two  before  the  menstrual  flow 
as  the  best  time  for  the  operation,  not  only  because  dilata- 
tion is  easier  then,  but  because  the  "  period  "  supervenes 
before  the  effects  of  the  operation  on  the  cervix  can  have 
passed  off,  and  thus  the  efficacy  of  the  operation  is  imme- 
diately put  to  the  test. 

Only  in  the  event  of  excessive  bleeding  from  the  dilated 
cervix  do  we  plug  the  cervical  canal  with  sterilized  gauze, 
which  is  withdrawn  in  twenty-four  hours. 

Dressing. — The  vagina  having  been  douched,  a  light 
plug  of  sterile  gauze  is  inserted  for  twenty-four  hours. 

After-treatment. — See  Chapter  xxxn.  The  patient  may 
get  up  in  a  week. 

Difficulties. — The  difficulties  of  dilatation  may  be 
described  under  four  heads  : 

i.  It  may  be  impossible  to  introduce  even  the  smallest 
dilator  through  the  external  os. 

2.  With  a  patent  external  os  the  passage  of  the  internal 

os  may  be  impossible. 

3.  With  patency  of  the  canal  it  may  yet  be  impossible 

to  increase  the  amount  of  dilatation  beyond  a 
certain  point  because  of  the  rigidity  of  the  cervical 
tissue. 

4.  As   the   dilatation   is   continued   the   length   of  the 

dilator  passing  into  the  canal  may  get  less  and 
less. 

1.  If  the  obstruction  is  at  the  external  os,  and  the 
sound  itself  will  not  pass,  the  direction  of  the  passage  should 
be  ascertained  by  a  fine  silver  probe,  and  the  vaginal  cervix 
should  then  be  split  bilaterally  with  a  pair  of  fine-pointed 
scissors,  so  as  to  open  up  the  lower  portion  of  the  cervical 
canal.  Any  haemorrhage  from  the  incision  can  easily  be 
controlled  by  suturing  the  split  cervix  with  silk  sutures 
after  the  dilatation  is  accomplished. 

2.  Difficulty  at  the  internal  os  is  also  often  surmounted 


DILATATION  OF  CERVIX  159 

after  lateral  incision  of  the  cervix,  but  where  the  stenosis 
at  this  point  is  very  extreme,  the  use  of  Fenton's  dilators 
must  be  led  up  to  by  the  passage  of  fine  probes. 

3.  If  the  cervix  is  rigid,  increasing  difficulty  may  be 
experienced  in  passing  the  dilators,  and  great  patience 
must  be  exercised,  for  while,  if  the  dilators  pass  easily, 
there  is  no  need  to  wait  more  than  a  few  seconds  before 
introducing  the  next  size,  in  cases  of  marked  rigidity  it 
may  be  necessary  to  leave  the  dilator  in  situ  for  several 
minutes  before  introducing  the  next  one.  If  on  removing 
the  dilator  the  internal  os  is  found  to  grip  the  instrument 
very  tightly,  this  is  an  indication  that  the  dilator  has 
not  been  left  in  long  enough  to  relax  the  muscular  spasm, 
and  it  should  therefore  be  re-introduced.  As  a  means 
of  softening  the  cervix,  especially  when  any  difficulty  in 
dilating  is  anticipated,  or  even  as  a  routine  treatment, 
a  hot  vaginal  douche,  followed  by  the  introduction  of 
glycerine  tampons  into  the  vagina  the  night  preceding 
the  operation,  will  often  be  found  to  accomplish  the  object 
in  view.  Some  authorities  still  advocate  the  use  of  tents 
the  night  before  the  operation.  In  our  opinion,  the  severe 
pain  they  cause  and  the  troublesome  manipulation  necessary 
for  their  introduction  entirely  outweigh  any  advantage 
obtained  by  their  use. 

The  cervix  of  a  virgin  or  of  a  sterile  married  woman 
is  more  rigid  than  that  of  one  who  has  borne  children. 
The  cervix  of  a  senile  uterus  is  often  very  difficult  to  dilate. 
It  may  also  be  remembered  that  the  cervix  is  particularly 
soft  for  two  or  three  days  preceding  the  period,  and  this 
is  a  good  time  to  dilate  it. 

4.  This  difficulty  is  very  common  with  beginners  in 
this  class  of  work,  and  has  probably  happened  to  everyone 
who  has  essayed  the  operation  of  dilatation  of  the  cervix. 
What  happens  is  this  :  the  first  few  dilators  are  passed 
easily,  which  leads  the  operator  to  introduce  the  dilators 
more  quickly  than  he  should  do.  The  lower  part  of 
the  canal  dilates  more  readily  than  the  upper  part,  and  the 


i6o  GYNAECOLOGICAL  SURGERY 

operator,  unconscious  of  the  fact,  fails  to  notice  that  the 
distance  to  which  each  dilator  is  passed  is  successively 
diminishing.  After  a  while  this  may  become  patent  to 
him,  and  he  will  have  to  retrace  his  steps  and  commence 
again  with  a  dilator  quite  low  down  in  the  series.  If  he 
fails  to  recognise  his  error,  he  will  mistake  the  dilated 
cervical  canal  for  the  whole  cavity  of  the  uterus  and  per- 
form   a    very   incomplete    curettage    or    exploration. 

Dangers. — -The  frequency  with  which  dilatation  of  the 
cervix  is  performed  and  the  ease  with  which  it  is  in 
most  cases  carried  out  have  caused  the  very  definite 
risks  associated  with  it  to  be  overlooked,  especially  by 
those  who  have  but  small  experience  in  this  class  of  work. 
There  are  few  operations  which  entail  such  a  respon- 
sibility on  the  gynaecologist  as  a  difficult  dilatation  of  the 
cervix.  The  operation  is  usually  carried  out  for  a  condition 
not  in  the  least  dangerous  to  life,  and  yet  its  careless  per- 
formance may  result  in  disasters  of  the  first  magnitude. 

Complications 

The  following  complications  have  often  occurred  : — 
i.  Lacerated  cervix. — Putting  aside  those  conditions 
in  which  the  cervix  is  very  soft,  as  just  after  a  mis- 
carriage, it  is  probable  that  nearly  always  when  the  cervix 
is  dilated  above  Fenton  No.  7  there  is  a  certain  amount 
of  laceration  of  cervical  tissue  in  the  neighbourhood  of 
the  internal  os.  Those  who  state  that  it  need  not  occur 
if  proper  care  be  taken,  speak  without  sufficient  evidence. 
At  any  rate,  whenever  the  dilatation  is  sufficient  to  admit 
a  finger,  fibres  of  the  cervix  will  be  found  lacerated,  in 
many  cases  to  a  much  greater  extent  than  the  operator 
would  have  suspected.  Again,  it  is  well  known  that  in 
most,  cases  dilatation  is  more  difficult  up  to  No.  7  than 
afterwards.  This  is  said  to  be  due  to  the  resistance  of 
the  internal  os,  which  later  on  is  stated  to  "  give,"  although 
what  really  happens  is  that  its  fibres  are  ruptured.  Lacera- 
tions such  as  these  do  not  constitute  an  appreciable  danger, 


DILATATION  OF  CERVIX  161 

Sometimes,  however,  owing  to  rigidity  of  the  cervix, 
or  to  excessive  force  being  used,  the  tissue  is  badly  lacerated. 
The  laceration  may  run  up  to  the  vaginal  vault  from  the 
external  os,  or  it  may  commence  in  the  neighbourhood 
of  the  internal  os,  so  that,  the  points  of  succeeding  dilators 
catching  in  it,  it  is  gradually  enlarged  until  the  uterus  is 
perforated  into  the  broad  ligament. 

A  bad  laceration  may  be  suspected  if,  when  there  has 
been  any  difficulty  in  dilatation,  the  instrument  suddenly 
and  without  warning  slips  in  very  easily.  In  many  cases 
the  cervical  tissue  can  be  felt,  and  sometimes  heard,  to  tear. 

The  risks  of  laceration  are  bleeding  and  sepsis.  Bleeding, 
unless  from  some  considerable  artery,  can  be  controlled  by 
plugging  the  cervix  with  gauze.  If  this  fails,  the  measures 
enumerated  under  the  heading  of  rupture  of  the  uterine 
artery  must  be  applied.  Sepsis  can  be  prevented  or  minim- 
ized by  strict  asepsis  during  the  operation  and  antisepsis 
afterwards. 

ii.  Rupture  of  the  uterine  artery. — This  rarely  occurs. 
When  it  does,  there  is  no  difficulty  in  recognizing  the  fact, 
the  bleeding  being  very  brisk,  and  arterial  in  character. 
It  is  caused  by  laceration  of  the  cervix.  If  the  laceration 
runs  up  from  the  external  os,  it  may  be  possible  to  see 
the  bleeding  spot,  in  which  case  it  can  be  seized  with 
forceps  and  secured  by  a  mattress-suture.  If  the  bleeding 
spot  cannot  be  identified,  owing  to  the  laceration  being 
limited  to  the  upper  part  of  the  cervical  canal,  the  vaginal 
cervix  on  the  bleeding  side  should  be  split  laterally,  the 
full  extent  of  the  laceration  exposed,  and  the  bleeding 
vessel  secured  as  before.  Short  of  this,  the  bleeding  vessel 
may  sometimes  be  controlled  by  a  pair  of  ring  forceps 
clamped  on  the  vaginal  vault,  one  blade  passed  up  the 
cervical  canal,  and  the  other  applied  outside  it.  If  none 
of  these  methods  is  sufficient,  the  uterine  artery  of  the 
damaged  side  will  have  to  be  exposed  and  tied  in  the  base 
of  the  broad  ligament  by  the  method  described  under 
Vaginal  Hysterectomy. 


162  GYNAECOLOGICAL  SURGERY 

iii.  Perforation  of  the  uterus.  —  Perforation  of  the 
uterine  wall  is  generally  due  either  to  carelessness  or  to 
ignorance  ;  in  rare  instances,  however,  it  cannot  be  avoided. 
In  dilatation  of  the  cervix,  not  only  should  no  undue  force 
be  used,  but  the  position  of  the  uterus  should  be  very 
carefully  determined,  since,  with  the  uterus  retroflexed 
or  anteflexed,  perforation  would  be  likely  to  occur  if  the 
operator  was  unaware  of  the  malposition.  The  dilator 
should  be  held  in  the  manner  indicated  in  Fig.  91,  and  not 
in  the  closed  hand,  for  if  held  properly  it  is  more  difficult 
to  employ  excessive  force,  and  the  extended  ringers  are 
ready  to  act  as  a  break.  Excessive  force  should  be  avoided, 
because  the  internal  os  may  suddenly  lacerate  and  allow 
the  dilator  to  rush  on,  and  so  perforate  the  uterus.  As 
regards  liability  to  perforate  through  ignorance,  the  ope- 
rator should  remember  that  in  cases  of  cancer,  of  retained 
gestational  products,  of  senility  and  of  superinvolution, 
the  uterine  wall  is  apt  to  be  so  soft  that  very  slight  pressure 
on  it  with  a  dilator  may  cause  perforation.  Lastly,  and 
rarely,  the  uterine  wall  may  be  very  soft  apart  from  any 
condition  which  would  make  one  suspicious,  and  it  is 
in  these  cases  that  perforation  cannot  be  entirely  guarded 
against. 

Perforation  into  the  peritoneal  cavity  may  be  suspected 
if  a  dilator  suddenly  slips  in  much  farther  than  the  one 
that  preceded  it.  There  is  no  doubt  that  in  some  cases 
the  uterine  body  stretches  during  dilatation,  and  therefore 
a  dilator  may  pass  farther  than  the  one  preceding  it  ;  this 
stretching,  however,  is  only  slight,  so  that  if  a  dilator 
passes  markedly  farther  than  the  sound  which  indi- 
cated the  length  of  the  uterine  canal,  perforation  may 
be  diagnosed.  To  confirm  this,  the  dilator  should  be 
immediately  withdrawn  and  the  cavity  carefully  examined 
with  the  uterine  sound,  when,  if  the  accident  has  occurred, 
the  perforation  will  soon  be  detected. 

Results  of  perforation. — Fortunately,  owing  to  the 
aseptic   surroundings   in   which   dilatation   is   carried   out 


DILATATION  OF  CERVIX  163 

at  the  present  day,  perforation  of  the  uterus,  as  a  rule, 
causes  no  bad  symptoms.  If,  however,  the  cervix  is  being 
dilated  for  some  septic  condition,  such  as  certain  cases 
of  retained  gestational  products,  sloughing  myomata,  or 
cancer,  the  patient  may  die  from  peritonitis.  Rarely,  severe 
hsemorrhage  into  the  peritoneal  cavity  may  be  caused. 
Perhaps  the  most  serious  result  possible  is  the  escape  of 
irritant  douche  solution  into  the  peritoneal  cavity  through 
a  perforation  in  the  uterus  of  which  the  surgeon  is  unaware. 

There  are  cases  on  record  in  which  the  uterus  has  been 
perforated  during  dilatation  for  the  removal  of  retained 
secundines,  and  a  piece  of  bowel  has  prolapsed  through 
the  rent ;  in  one,  the  operator  pulled  down  and  cut  off 
6  in.  of  bowel  before  he  became  aware  of  his  mistake.  In 
this  case  the  abdomen  was  opened  and  the  divided  ends 
of  the  bowel  were  successfully  sutured. 

If  the  uterus  is  perforated,  the  operation  should  be  at 
once  abandoned,  and  the  uterus  lightly  plugged  with 
sterile  gauze.  No  douche  should  on  any  account  be  given. 
A  careful  watch  must  then  be  kept  for  signs  of  internal 
hsemorrhage  or  of  peritonitis. 

Hemorrhage  after  perforation. — In  the  case  of  haemorrhage 
it  is  noticed,  on  the  patient  recovering  from  the  anaesthetic, 
that  the  pulse  is  much  faster  than  is  usual  after  a  simple 
dilatation,  and  the  patient  complains  of  severe  abdominal 
pain,  a  symptom  which  is  never  present  in  an  ordinary 
case.  She  is  pallid,  cold,  and  restless,  and  examination 
of  the  abdomen,  even  at  this  early  period,  discloses  much 
suprapubic  rigidity.  Symptoms  such  as  these  indicate 
immediate  exploration  of  the  pelvis  through  an  abdominal 
incision,  and  the  perforation,  having  been  located,  must, 
if  possible,  be  sutured.  In  cases,  however,  where  the 
laceration  is  very  extensive  and  the  haemorrhage  uncon- 
trollable by  sutures,  the  uterus  should  be  removed,  pre- 
ferably by  the  subtotal  method.  Finally,  if  the  cavity 
of  the  perforated  organ  is  known  to  be  septic,  the  treat- 
ment offering  the   best   chance   to  the  patient  is   a  total 


164  GYNECOLOGICAL  SURGERY 

hysterectomy,   the  vagina  being  left  wide  open  into  the 
pelvis  to  secure  free  drainage. 

Peritonitis  ajter  perforation. — After  perforation,  peri- 
tonitis arises  in  three  ways  : 

(i)  Direct  infection  of  the  pelvis  by  organisms  from 
the  interior  of  the  uterus. 

(2)  The  presence  of  blood  in  the  peritoneal  cavity, 

not    sufficient,    perhaps,    to    give    rise    to    the 
classical  signs  of  internal  haemorrhage. 

(3)  Escape    of   the    douching   solution   through   the 

perforation. 

(1)  In  the  case  of  direct  conveyance  of  sepsis  from  the 
uterus  to  the  peritoneum,  the  symptoms  do  not  come  on 
for  at  least  twelve  hours  after  the  operation,  and  then 
present  the  ordinary  characters  of  peritonitis,  local  or 
general,  as  the  case  may  be. 

(2)  With  peritonitis  the  result  of  hsemorrhage,  signs  of 
peritoneal  irritation  are  present  more  or  less  from  the  time 
the  patient  recovers  from  the  anaesthetic,  and  steadily 
increase  for  the  next  twenty-four  hours.  The  physical 
signs  are  those  of  a  pelvic  haematocele. 

(3)  The  introduction  of  irritant  douche  solutions  into 
the  pelvis  gives  rise  to  immediate  and  very  violent  symp- 
toms. With  the  introduction  of  the  more  commonly  used 
mercurial  solution  the  patient  is  in  great  pain,  the  pulse 
is  very  fast,  the  lower  abdomen  soon  becomes  distended 
and  rigid,  and  in  about  four  hours  a  violent  diarrhoea 
begins. 

The  treatment  of  peritonitis  following  perforation  of 
the  uterus  will  depend  upon  the  knowledge  the  operator 
has  of  the  cause  and  of  the  degree  of  the  symptoms  ex- 
hibited. Where  the  introduction  of  irritant  douche  solutions 
can  be  excluded  and  the  symptoms  are  not  fulminant,  it 
is  best  to  wait,  for  in  many  cases  the  peritoneal  reaction 
remains  local,  and  after  some  days  the  pain  and  fever 
subside.  If,  however,  it  is  known  or  strongly  suspected 
that  a  poisonous  solution  has  escaped  into  the  pelvis,  or 


DILATATION  OF  CERVIX  165 

if  early  and  rapidly  augmenting  symptoms  should  present 
themselves,  the  abdomen  should  be  opened,  the  rent 
sutured,  the  pelvis  mopped  out  and  drained  both  through 
the  vagina  and  through  the  abdominal  wound.  In  these 
cases  it  is  bad  practice  to  remove  the  uterus,  since  the  in- 
fection of  the  peritoneum  has  already  occurred,  and  the 
operation,  besides  increasing  the  shock,  opens  up  large 
areas  of  healthy  tissue  to  infection. 

Prolapsed  intestine. — If  the  bowel  has  prolapsed  through 
a  uterine  rent,  the  proper  treatment  is  to  open  the  abdo- 
men, carefully  pull  out  the  bowel,  clean  it  if  healthy,  and 
resect  it  if  damaged.  The  rent  in  the  uterus  is  then  to  be 
sewn  up,  or  the  organ  removed,  as  seems  most  advisable 
at  the  time. 

Perforation  into  the  broad  ligament. — Perforation  into  the 
broad  ligament  is  caused  in  a  somewhat  different  manner. 
Laceration  of  the  cervix  first  takes  place  in  the  neighbour- 
hood of  the  internal  os  without  the  operator  being  aware 
of  the  fact.  The  points  of  the  succeeding  dilators  are  then 
thrust  into  this  laceration,  and  the  uterine  wall  is  gradually 
torn  until  the  dilator  slips  through  into  the  broad  ligament. 
This  occasions  more  bleeding  than  is  usual,  which  leads 
to  a  digital  examination  and  the  discovery  of  the  accident. 
Its  results  may  be  nil  if  the  operation  has  been  carried  out 
under  aseptic  conditions  and  no  large  artery  has  been 
torn  across.  On  the  other  hand,  a  hematoma  of  the  broad 
ligament  may  rapidly  form,  or  at  a  later  date  the  symptoms 
of  pelvic  cellulitis  may  manifest  themselves. 

Where  the  hsematoma  is  small,  the  only  symptom  is 
pain  referred  to  that  side,  and  within  a  short  time  a  swelling 
can  be  felt  in  the  broad  ligament.  In  exceptional  cases, 
however,  the  effusion  of  blood  is  very  large,  and,  lifting 
the  peritoneum  off  the  side  wall  of  the  pelvis,  mounts  into 
the  iliac  fossa,  or  even  into  the  loin.  Haematomata  of  this 
magnitude  give  rise  to  the  ordinary  signs  of  internal  haemor- 
rhage, and  a  very  definite  swelling,  the  outer  limits  of  which 
are  dull  on  percussion,  can  usually  be  felt.    We  have  noted, 


166  GYNAECOLOGICAL   SURGERY 

however,  that  in  extremely  rapid  effusions  of  blood  under 
the  posterior  parietal  peritoneum  great  intestinal  disten- 
sion occurs,  due  probably  to  interference  with  the  splanchnic 
nerves.  Such  distension  may  mask  the  tumour  formed 
by  the  haematoma.  A  similar  condition  of  affairs  is  seen 
in  acute  haemorrhagic  pancreatitis. 

iy.  Rupture  of  a  pyosalpinx. — If  on  bimanual  examina- 
tion it  is  found  that  the  uterus  is  fixed,  and  there 
is  some  thickening  in  the  fornices,  it  behoves  the  operator, 
if  he  considers  dilatation  a  necessity,  to  use  every  care. 
If  he  has  diagnosed  a  pyo-salpinx,  he  would  not,  of  course, 
essay  dilatation  of  the  cervix  before  that  condition  was 
cured,  for  fixation  of  the  uterus  is  commonly  observed 
with  salpingitis,  and  forcibly  moving  a  fixed  uterus  in 
such  a  manner  is  liable  to  set  free  any  collection  of  pus 
in  its  immediate  neighbourhood. 

The  rupture  of  a  pyo-salpinx  is  a  most  serious  disaster, 
and  may  set  up  in  a  few  hours  a  peritonitis  which  may 
prove  fatal.  Even  supposing  that  the  diseased  tubes  do 
not  contain  pus,  the  disturbance  of  the  parts  caused  by 
the  dilatation  may  accentuate  any  symptoms  of  sal- 
pingitis already  present,  or  may  light  up  anew  one  that 
is  quiescent. 

The  above  remarks  also  appertain  to  ovarian  abscess. 

y.  Salpingitis — As  we  have  already  said,  salpingitis  is 
sometimes  present  in  a  minor  degree  before  the  operation, 
and  may  be  accentuated  by  the  manipulations  incident 
to  its  performance.  More  commonly,  however,  it  is  a 
direct  result  of  the  operation,  and  may  be  brought  about 
in  three  ways  : 

(i)  If  the  cavity  of  the  uterus  be  already  infected,  there 
is  a  risk  of  the  uterine  secretion  being  forced  into  the  tube 
by  the  piston-like  action  of  the  dilator. 

(2)  The  cavity  of  the  uterus  may  be  infected  by  the 
instruments  used,  and  this  infection  may  subsequently 
spread  to  the  tube. 

(3)  Subsequently  to  the  operation,  owing  to  some  failure 


DILATATION  OF  CERVIX  167 

of  asepsis  in  the  after-treatment,  organisms  may  ascend 
the  genital  canal  and  infect  the  tube.  The  symptoms  are 
those  of  pelvic  peritonitis.  The  time  of  onset  of  the  disease 
varies  ;  most  of  the  cases  occur  within  a  fortnight  of  the 
operation,  many  of  them  within  a  few  days.  It  is,  however, 
to  be  remarked  that  endometritis  set  up  by  dilatation 
may  be  responsible  for  an  attack  of  salpingitis  many  months 
later. 

vi.  Peritonitis. — Of  the  several  causes  of  peritonitis 
after  dilatation,  perforation  of  the  uterus,  extension  from 
salpingitis,  and  rupture  of  a  tubal  or  ovarian  abscess  have 
already  been  dealt  with.  But  the  condition  may  also 
result  from  a  direct  extension  of  infection  through  the 
uterine  lymphatics  from  a  wound  in  its  lining  mem- 
brane. 

Peritonitis  following  dilatation  of  the  cervix  is  local 
to  the  pelvis,  as  a  rule,  but  occasionally,  when  the  organism 
is  of  a  very  virulent  nature  or  the  infection  overwhelming 
in  character,  e.g.  a  ruptured  pyo-salpinx,  it  becomes  rapidly 
generalized.  The  earlier  the  symptoms  appear  the  graver 
is  the  outlook.  In  the  worst  cases  no  pelvic  tumour  can 
be  felt.  In  those  of  lesser  severity,  a  mass  lying  behind 
or  around  the  uterus  can  usually  be  felt  within  a  few  days. 
This  swelling  is  a  conglomerate  consisting  of  an  inflamed 
tube,  a  mass  of  blood-clot  or  collection  of  pus,  singly  or  in 
association  as  the  case  may  be,  and  surrounded  by  ad- 
herent intestines  and  thickened  omentum. 

Treatment  of  peritonitis. — The  onset  of  peritonitis 
after  dilatation  is  a  serious  disaster,  and  the  proper  course 
for  the  surgeon  to  pursue  will  be  a  matter  of  the  greatest 
concern  to  him.  The  difficulty  that  presents  itself  is  to 
decide  whether  the  peritoneal  cavity  should  be  explored 
or  not.  Each  case  must  be  treated  on  its  merits,  and 
no  general  rule  can  be  laid  down.  Where  the  physical 
signs  are  entirely  local,  it  is  better  to  wait  in  the  hope 
that  the  inflammation  may  subside.  In  this  case,  hot 
fomentations  with   glycerine   and  belladonna  or  laudanum 


168  GYNECOLOGICAL  SURGERY 

may  be  applied  to  the  abdomen  and  morphia  given  internally 
for  the  relief  of  the  pain,  whilst  vaginal  injections  of  some 
antiseptic  solution  at  no°  F.  often  afford  relief  and 
favour  absorption.  Fever  should  be  treated  with  quinine. 
If  the  symptoms  increase,  and  there  are  unequivocal  signs 
of  pus-formation,  the  abdomen  should  be  opened,  the 
condition  dealt  with,  and  the  pelvis  drained.  All  cases 
presenting  the  signs  of  general  peritonitis  should  be  at 
once  treated  in  the  manner  described  at  p.  601. 

yii.  Pelvic  cellulitis. — This  is  due  to  direct  spread  of 
infection  through  a  laceration  of  the  cervix  or  body  of  the 
uterus,  usually  the  former.  The  symptoms  may  begin  any 
time  within  the  first  three  weeks,  most  commonly  occurring, 
as  after  labour,  from  the  tenth  to  the  fourteenth  day. 
With  a  rise  of  pulse  and  temperature  a  tender  swelling  in 
the  affected  broad  ligament  is  discovered.  As  a  rule,  the 
disease  remains  strictly  local,  and  tends  after  about  a 
week  to  get  well.  More  rarely  the  swelling  may  extend  up 
into  the  iliac  fossa,  or  a  definite  abscess  may  form. 

Occasionally  these  cases  are  further  complicated  by 
femoral  thrombosis  and  severe  signs  of  general  sepsis. 

Treatment  of  pelvic  cellulitis. — Unless  there  is  a 
definite  collection  of  pus,  the  patient  may  be  treated  in 
a  way  similar  to  that  indicated  for  slight  local  peritonitis. 
If  pus  forms,  it  should  be  evacuated  without  delay 
by  an  incision  through  the  vaginal  fornix ;  a  drainage-tube 
should  afterwards  be  inserted. 

viii.  Injury  to  the  capsule  of  a  myoma. — If  the  uterus 
which  is  being  dilated  contains  a  submucous  myoma,  the 
point  of  a  dilator  may  penetrate  its  capsule.  In  such  an 
event  no  evil  results  may  follow,  but  occasionally  the 
tumour  is  gradually  extruded  through  the  rent  with  much 
haemorrhage  and,  usually,  more  or  less  septic  symptoms. 
In  other  cases,  acute  septic  changes  may  be  set  up  in  the 
tumour  without  extrusion.  The  dilatation  of  a  myomatous 
uterus  is,  therefore,  a  proceeding  associated  with  definite 
danger. 


SUTURE    OF    LACERATED    CERVIX       169 

TRACHELORRHAPHY 

Indications. — This  operation  is  performed  for  those 
cases  of  lacerated  cervix  in  which  the  exposed  surfaces 
of  the  laceration  are  covered  as  the  result  of  chronic  cervi- 
citis with  a  redundant  gland-bearing  epithelium  giving 
rise  to  a  profuse  leucorrhceal  discharge.  It  has,  however, 
the  disadvantage  that  it  leaves  a  strip  of  diseased  mucosa 
in  the  restored  cervical  canal,  and  thus  sometimes  fails  in 
its  object  of  stopping  discharge.  It  is  not  a  good  operation 
when  much  hypertrophy  and  elongation  of  the  cervix 
exists,  since  it  does  not  remedy  this  condition.  In  such 
cases  tracheloplasty  or  amputation  of  the  vaginal  cervix 
is  preferable. 

In  those  cases  of  repeated  abortion  in  which  no  cause 
can  be  found  other  than  that  of  the  lacerated  cervix,  the 
operation  of  trachelorrhaphy  has  proved  successful. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments.  —  Clover's  crutch,  Auvard's  speculum, 
two  volsellae,  dissecting  forceps,  four  pairs  of  long  pres- 
sure-forceps, scalpel,  uterine  sound,  four  curved  needles 
No.  7,  silk  No.  2,  silkworm-gut,  shot  and  coil,  shot 
compressors. 

Operation. — Auvard's  speculum  is  inserted  into  the 
vaginal  canal,  and  then,  with  volsellse  on  the  anterior 
and  posterior  lips,  the  cervix  is  brought  to  the  vulval 
orifice.  The  volsellas  are  now  separated  so  that  the  lacera- 
tion is  opened  up  as  much  as  possible  (Fig.  92),  the  anterior 
volsella  being  given  to  an  assistant  to  hold.  An  incision 
is  made  across  the  cervix  in  the  receding  angle  between 
the  two  lips,  thus  deliberately  deepening  the  laceration 
(Fig.  93).  The  surgeon  proceeds  to  mark  out  with  a  scalpel 
on  both  lips  of  the  cervix  the  limits  of  the  pieces  of  mucous 
membrane  he  proposes  to  remove  (Fig.  94).  Four  areas 
of  mucous  membrane  having  thus  been  delineated,  this 
tissue  is  dissected  off  (Fig.  95).  In  dissecting  off  the  mucous 
membrane,   it  must  be  remembered  that  a  narrow  piece 


170 


GYNAECOLOGICAL  SURGERY 


of  this  structure  has  to  be  left  on  each  side  of  the  middle 
line  to  form  a  lining  for  the  cervical  canal  when  it  is  remade  ; 
otherwise  as  much  mucous  membrane  must  be  dissected 
off  as  is  possible,  special  care  being  taken  completely  to 
remove  all  the  mucous  membrane  together  with  the  sub- 
jacent cicatricial  tissue  at  the  receding  angle  of  the  lacera- 


Fig.  92.— Trachelor- 
rhaphy :  Exposure 
of  the  laceration. 


tion.  During  the  dissection  of  these  flaps  the  bleeding 
may  be  rather  free,  but  will,  as  a  rule,  stop  when  the  raw 
surfaces  are  approximated.  Should,  however,  the  haemor- 
rhage obstruct  the  field  of  operation,  it  can  usually  be 
kept  in  check  by  an  assistant  directing  a  stream  of  hot 
water  on  to  the  cervix. 

The  lacerated  surfaces  having  been  sufficiently  denuded, 


TRACHELORRHAPHY 


171 


silk  sutures — as  a  rule,  three  on  each  side  will  be  sufficient 
— are  passed  by  means  of  a  curved  needle  held  in  a  pair 
of  pressure-forceps.  The  needle  is  inserted  in  the  anterior 
lip  at  the  outer  edge  of  the  laceration  close  up  to  its  receding 
angle.  It  is  then  carried  through  the  cervical  tissue  deeply 
to  the  raw  surface,  and  brought  out  at  the  edge  of  the 


Fig.  93. — Deepening  the 
laceration. 


mucous  membrane  which  has  been  left  as  a  lining  for  the 
cervical  canal.  It  is  now  re-introduced  into  the  posterior 
lip  at  the  edge  of  mucous  membrane,  opposite  its  point  of 
exit  in  the  anterior  lip,  carried  through  the  cervical  tissue 
deeply  to  the  raw  surface,  and  brought  out  at  the  outer  edge 
of  the  laceration  (Fig.  96).  The  remaining  sutures  are 
passed  on  each  side  in  a  similar  manner.  The  raw  surfaces 
can  thus  be  accurately  approximated  without  any  suture 


172 


GYNAECOLOGICAL  SURGERY 


intervening  between  them  which,  acting  as  a  foreign  body, 
might  prevent  their  union  (Fig.  97). 

The  sutures  having  been  tied,  a  sound  is  passed  into  the 
uterus  to  ensure  that  the  cervical  canal  is  patent,  and  the 
vagina  is  well  douched  with  biniodide  of  mercury,  1 — 4,000. 


Fig.  94. — Demarcation  of  the  areas  of  denudation. 


If  the  surgeon  prefers  to  remove  the  sutures,  silkworm- 
gut  must  be  used  and  fastened  with  shot  and  coil. 

Failures. — The  failures  of  this  operation  are  due,  as 
a  rule,  to  an  insufficient  amount  of  mucous  membrane 
being  removed,  to  the  receding  angle  of  the  laceration  not 
being  properly  denuded,  and  to  the  too  early  removal  of 
the   sutures. 


TRACHELORRHAPHY 


m 


Dressing  and  after-treatment. — See  Chapter  xxxn.  If 
silkworm-gut  sutures  have  been  used,  they  are  removed 
on  the  tenth  day,  the  shot  being  cut  off  with  scissors,  the 
coil  removed,  and  the  suture  pulled  out.  If  silk  is  used, 
the  sutures  can  be  left  in.  The  patient  gets  up  on  the 
twelfth  or  fourteenth  day. 


Fig.  95. — Denudation  of  the  demarcated  areas. 

TRACHELOPLASTY 

Indications. — In  this  operation  the  entire  inner  surfaces 
of  the  lips  of  the  laceration  are  removed.  It  is  indicated 
in  the  same  circumstances  as  trachelorrhaphy,  to  which, 
in  our  opinion,  it  is  preferable. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments.  —  Clover's    crutch,     Auvard's     speculum, 


i74 


GYNECOLOGICAL  SURGERY 


Fenton's  dilators  I  to  12,  two  volsellse,  six  pairs  of  long 
pressure-forceps,  dissecting  forceps,  curette,  sharp  scoop, 
uterine  sound,  bladder-sound,  scalpel,  half-circle  needles 
No.  9,  silk  Nos.  2  and  4. 

Operation. — -The    cervical    canal    should  be   dilated  to 
12    Fenton    and    thoroughly    scraped,    and    the    body,    if 


Fig.  96. — Trachelor- 
rhaphy :  Introduc- 
tion of  the  sutures. 


need  be,  curetted.  This  proceeding,  besides  removing  the 
diseased  mucosa  higher  up,  renders  the  subsequent  intro- 
duction of  the  sutures  much  easier,  from  the  dilated  state 
of  the  canal.  This  done,  the  operator  steadies  the  lips 
and  excises  the  inner  surface  of  each,  the  two  lines  of 
incision  meeting  on  the  lateral  aspect  of  the  cervix  just 
above  the  receding  angle  of  the  laceration.  A  wedge- 
shaped  piece   of  tissue  is   thus   removed   (Fig.   98).     The 


TRACHELOPLASTY 


i75 


Fig.  98.—  Tracheo- 
plasty :  Removal  of 
the    diseased    areas. 


176  GYNAECOLOGICAL  SURGERY 

anterior  and  posterior  lips,  now  attenuated  into  a  couple 
of  flaps,  are  sutured  at  their  middle  portions  to  the  anterior 
and  posterior  halves  of  the  edge  of  the  lumen  of  the  cervical 
canal,  thus  joining  the  mucous  membrane  of  the  vaginal 
surface  of  the  lips  to  that  of  the  cervical  canal  (Fig.  99). 


Fig.  99. — Suturing  the  flaps  to  the  ridge  of  the 
cervical  canal. 

Right  and  left  of  this  the  two  flaps  are  directly  united 
together  (Fig.  100).  The  sutures  being  tied  and  cut 
short,  the  vagina  is  douched  with  a  1 — 4,000  solution  of 
mercury,  and  packed  with  sterile  gauze  for  twenty-four 
hours. 


AMPUTATION   OF  VAGINAL  CERVIX     177 

Dressing  and  after-treatment. — See  Chapter  xxxn.  The 
patient  may  get  up  in  fourteen  days. 

AMPUTATION    OF   THE   VAGINAL   CERVIX 
Indications — This  operation    is  performed    for    hyper- 
trophic elongation  of  the  cervix,  congenital  elongation  of 
the   cervix,   and  severe  cases   of  laceration   of  the   cervix 
with  marked  hypertrophy  of  the  lacerated  portion.     It  is 


Fig.  100.— Completing 
the  suture  of  the  flaps. 


also  indicated  in  cases  of  leucorrhcea  when  associated  with 
a  severe  erosion  which  a  thorough  scraping  with  a  sharp 
spoon  has  failed  to  cure.  It  is  further  indicated  in  those 
cases  of  old-standing  cervical  erosion  which,  by  reason  of 
their  tendency  to  bleed,  their  irregular  red  surface  and 
indurated  feel,  suggest  that  they  may  be  in  many  cases 
the  precursors  of  cancer. 

Preparation   of  the   patient. — -See  pp.  78-82. 

Instruments.  —  Clover's  crutch,  Auvard's  speculum, 
Fenton's   dilators   1  to   12,  volsella,  vaginal  retractors,  six 

M 


178 


GYNECOLOGICAL  SURGERY 


pairs  of  long  pressure-forceps,  dissecting  forceps,  curette, 
uterine  sound,  bladder-sound,  scalpel,  curved  needles  No.  7, 
silk  Nos.  1  and  2. 

Operation. — Before    commencing    this    operation  it  will 
be  found  a  useful  plan  to  dilate   the   cervical   canal  up  to 


Fig.    101. — Amputation 

of   the    vaginal  cervix : 

Incision  of  the  mucous 

membrane. 


Fenton  12.  This  proceeding  greatly  facilitates  the  intro- 
duction of  the  sutures  from  the  cervical  canal  and  also 
renders  the  covering-in  of  the  raw  surface  easier. 
If  the  operation  is  being  performed  for  inflammatory 
disease,    the    uterus    should   be    curetted. 

i.  Identifying  the  limits   of  the   bladder. — The  bladder- 
sound  is  passed  into  the  bladder  to  ascertain  its  extent. 


AMPUTATION  OF  VAGINAL  CERVIX      179 

ii.  Removing  the  cervix.  —  Auvard's  speculum  having 
been  inserted,  the  cervix  is  grasped  by  the  volsella,  and 
a  circular  incision  is  made  through  the  mucous  membrane 
at  whatever  level  is  determined  on  (Fig.  101).  The  upper 
edge  of  the  incised  mucous  membrane  is  then  separated  for 


Fig.  102.— Reflection  of  the 
cuff. 


some  little  distance  with  the  handle  of  the  scalpel,  forming 
as  it  were  a  cuff  all  round  (Fig.  102),  and  the  cervix  is 
amputated  at  the  junction  of  the  reflected  mucous  membrane 
(Fig.  103).  Purse-string  sutures  of  silk  No.  1  are  now 
inserted,  so  that  the  mucous  membrane  of  the  vaginal 
surface  is  carefully  joined  to  that  of  the  cervical  canal. 
The     needle,    threaded    with    silk,     is    passed     from     the 


i8o 


GYNECOLOGICAL  SURGERY 


cervical  canal  outwards  through  the  uterine  wall,  and 
emerges  on  the  surface  of  the  raw  stump  about  a  quarter 
of  an  inch  from  the  margin  of  the  canal.  It  is  then  carried 
through  the  cut  edge  of  the  vaginal  mucous  membrane 
opposite  its  point  of  entrance,  and  is  continued  along  one- 


Fig.  103.— The 
amputation. 


third  of  its  circumference.  It  is  now  re-introduced  through 
the  raw  surface  of  the  stump  into  the  cervical  canal 
close  to  the  point  from  which  it  originally  started  (Fig. 
104).  Three  of  these  sutures  will  usually  suffice  to 
approximate  neatly  the  vaginal  and  cervical  mucous 
membrane  (Fig.  105).  If  the  bleeding  from  the  stump 
is   more   than  can  be  controlled  by  the  pressure  of  these 


AMPUTATION  OF  CERVIX 


181 


sutures,  it    may  be    arrested    by    one  or    more   mattress- 
sutures   passed   through   the   tissue   of   the  stump. 

Dressing  and    after-treatment.  —  See     Chapter     xxxn. 
The  patient  gets  up  on  the  fourteenth  day. 


Fig.  104. — Insertion  of  the  sutures. 


SUPRAVAGINAL  AMPUTATION  OF  THE  CERVIX 

Indications. — In  very  severe  cases  of  laceration,  in  which 
the  tear  has  run  up  into  the  vaginal  vault,  if  it  is  thought 
advisable  to  remove  the  cervix,  supravaginal  amputation 
must  be  performed,  and  this  operation  is  also  indicated  in 
cases  of  hypertrophic  elongation  of  the  supravaginal  portion 
of  the  cervix.  It  is  not,  however,  a  good  operation,  owing 
to  the   tendency   for   stenosis   to   occur   as    a    result.     Its 


182 


GYNECOLOGICAL  SURGERY 


performance  for  carcinoma  of  the  cervix  has  been  almost 
abandoned. 

Operation. — The  cervix  having  been  seized  with  a 
volsella,  the  mucous  membrane  is  incised  all  round  at 
the  junction  of  the  cervix  and  vagina.     This  mucous  mem- 


x 


Fig    105. — Securing  the  sutures. 


brane  is  then  reflected  in  front,  together  with  the  bladder, 
and  at  the  back  and  sides,  with  the  handle  of  the  scalpel 
or  the  ringer,  as  far  as  the  level  of  the  uterine  arteries, 
which  will  be  felt  pulsating  one  on  each  side.  These  are 
secured  with  a  No.  4  silk  ligature  by  means  of  Worrall's 
needle  (Fig.  18a),  close  to  the  cervix,  so  as  to  avoid  dam- 
aging the   ureter,     The   cervix   is   then   amputated   below 


CERVICOVESICAL  FISTULA  183 

the  level  of  these  ligatures,  and  the  cut  edge  of  the  vagina 
and  lining  of  the  cervical  canal  are  approximated  by 
sutures  of  No.  1  silk  as  described  at  p.  179. 

Dangers. — When  the  cervix  has  to  be  removed  high 
up,  the  bladder  or  rectum  may  be  wounded. 

The  recto-vaginal  fossa  may  be  opened,  in  which  case 
it  should  be  closed  by  a  silk  suture. 

The  ureters  may  be  included  in  the  ligatures  that  secure 
the  uterine  artery.  For  results  and  treatment  of  this 
accident,  see  pp.  251  and  656. 

The  ligatures  on  the  uterine  artery  may  slip,  causing 
secondary  haemorrhage.  If  so,  the  patient  must  be  again 
anaesthetized  and  the  bleeding-point  secured. 

Peritonitis  or  cellulitis  may  result  from  septic  infection. 
These  conditions  must  be  treated  on  the  ordinary  lines. 

Dressing  and  after-treatment. — See  Chapter  xxxn. 

CERVICO-VESICAL    FISTULA 

Preparation    of    the    patient. — See    pp.    78-82.      It    is 

absolutely  necessary  to  cure  cystitis,  if  it  exists,  before 
attempting  the  operation. 

Instruments. — Clover's  crutch,  Auvard's  speculum,  dis- 
secting forceps,  six  pairs  of  long  pressure-forceps,  volsella, 
vaginal  retractors,  scalpel,  scissors,  two  curved  needles, 
two  No.  7  and  two  half-circle  No.  11,  silk  Nos.  1  and  2. 

There  are  two  varieties  of  this  condition  :  (1)  where  the 
fistula  lies  at  the  bottom  of  a  deep  laceration  of  the  vaginal 
cervix  ;  (2)  where  the  communication  is  through  the  wall 
of  the  cervix  some  distance  above  the  vaginal  vault. 

Operation. — In  the  first  variety,  the  closure  of  the 
fistula  should  be  combined  with  a  trachelorrhaphy.  The 
edges  of  the  vaginal  mucous  membrane  which  abut  on  the 
laceration  must  be  undermined  and  retracted  sufficiently 
to  get  a  clear  view  of  the  opening  in  the  bladder-wall.  The 
bladder-wall  is  separated  for  half  an  inch  around  the 
opening,  and  the  aperture  is  closed  with  a  purse-string 
suture  by  preference.     The  edges  of  the  vaginal  mucous 


184  GYNAECOLOGICAL  SURGERY 

membrane  and  the  cervical  laceration  are  pared,  and  a 
series  of  sutures  is  inserted,  beginning  at  the  end  of  the 
laceration  where  it  encroaches  on  the  vaginal  vault,  and 
continued  downwards  as  far  as  the  external  os,  thus  closing 
the  vaginal  mucous  membrane  over  the  aperture  in  the 
bladder  and  restoring  the  integrity  of  the  vaginal  cervix. 

In  the  second  variety,  the  bladder  must  be  turned 
entirely  off  the  supravaginal  cervix,  following  the  technique 
of  the  first  step  of  the  vaginal  hysterectomy  (p.  227),  and 
the  hole  in  it  must  be  separately  closed  by  a  purse-string 
silk  suture.  The  vaginal  cervix  is  now  pulled  well  down, 
and  the  perforation  on  its  anterior  wall  freshened  and 
closed  with  silk  sutures.  Finally,  the  cut  mucous  membrane 
of  the  anterior  vaginal  fornix  is  united  by  silk  sutures. 

Dressing  and  after-treatment. — See  Chapter  xxxn.  If 
No.  1  silk  sutures  be  used,  there  is  no  necessity  to  remove 
them.     The  patient  may  get  up  in  ten  days. 

UTERO-VESICAL    FISTULA 

This  complication  is  of  very  rare  occurrence.  It  must 
be  dealt  with  by  an  abdominal  operation.  The  bladder 
should  be  separated  from  the  uterus,  and  the  openings  in 
both  organs  carefully  closed  with  fine  silk  sutures. 

An  alternative  method  would  be  to  remove  the  uterus 
and  then  suture  the  vesical  opening. 


CHAPTER    IX 

OPERATIONS    ON    THE    CAVITY    OF   THE 
UTERUS 

CURETTING 

General  remarks  and  indications. — We  are  of  opinion  that 
inflammatory  disease  of  the  cervix,  and  cervix  only,  is 
extremely  common  in  parous  women,  and  not  uncommon 
in  virgins  as  well,  whilst  a  corresponding  condition  of  the 
corporeal  endometrium  is  comparatively  rare.  The  only 
symptom  of  chronic  cervicitis  is  leucorrhcea,  and  on  ex- 
amination of  the  cervix  an  erosion,  which  is  its  outward 
visible  sign,  will  always  be  found. 

Corporeal  endometritis  does  not  cause  a  leucorrhceal 
discharge,  although  nearly  always  associated  with  it 
because  of  the  coexistent  cervicitis.  The  secretion  of  the 
corporeal  glands  is  a  watery,  not  a  mucous  fluid.  This 
is  extremely  well  seen  where  a  great  overgrowth  of  the 
corporeal  endometrium  coexists  with  a  healthy  cervix. 
Such  a  condition  occurs  in  some  cases  of  uterine  myomata, 
a  leading  feature  then  being  a  copious  watery  discharge 
from  the  uterus.  Where  this  watery  discharge  is  not 
present  there  is  certainly  no  hypertrophy  of  the  endo- 
metrium, inflammatory  or  otherwise. 

The  other  symptoms  associated  with  corporeal  endo- 
metritis are  excessive  menstrual  haemorrhage  or  irregular 
losses  between  the  periods,  but  as  these  often  depend  on 
diseased  conditions  of  the  deeper  parts  of  the  uterine  wall, 
their  occurrence  is  not  pathognomonic  of  changes  in  the 
endometrium. 

The  corporeal  endometrium  is  the  softest  "  mucous 
membrane  "  in  the  body ;  it  is  succulent  and  thick,  and  strips 

i85 


186  GYNECOLOGICAL  SURGERY 

off  readily  with  the  curette.  The  cervical  endometrium, 
on  the  other  hand,  can  scarcely  be  described  as  a  "  mem- 
brane "  at  all.  It  consists  of  a  surface  layer  of  short 
columnar  cells  standing  almost  directly  on  the  subjacent 
muscle  in  which,  most  deeply  embedded,  are  the  racemose 
mucus-producing  cervical  glands.  The  healthy  vagina  con- 
tains many  organisms,  and  their  passage  up  the  cervical 
canal  is  unimpeded.  They  do  not,  however,  find  their 
way  beyond  the  internal  os.  In  pathological  infections  of 
the  vagina  (e.g.  by  the  gonococcus)  the  same  holds  true, 
as  a  rule.  Gonococcic  endocervicitis  is  constantly  present, 
while  gonococcal  endometritis  is  fortunately  comparatively 
rare.  A  want  of  appreciation  of  these  facts  of  anatomy 
and  pathology  is  the  reason  of  the  frequency  with  which 
the  curette  is  used  in  inappropriate  conditions.  One  con- 
stantly sees  the  corporeal  endometrium  stripped  off  by  the 
blunt  curette  where  the  cervix  alone  is  at  fault,  while  the 
diseased  cervical  glands,  the  sole  origin  of  the  leucorrhceal 
discharge,  are  left  uninterfered  with  because  nothing  less 
than  a  sharp  scoop  strongly  applied  suffices  to  eradicate 
them  from  the  dense  matrix  by  which  they  are  surrounded. 
In  many  of  the  cases  proper  for  curetting,  it  is  the  cervical 
endometrium  alone  which  should  be  erased. 

To  sum  up,  leucorrhcea  per  se  is  an  indication  for  curet- 
tage of  the  cervix  only.  Abnormal  haemorrhage,  pain,  and 
uterine  enlargement,  though  they  may  indicate  corporeal 
endometritis,  are  much  more  likely  to  be  due  to  some  altered 
condition  of  the  deeper  parts  of  the  uterine  wall  which  a 
superficial  denudation  of  the  mucosa  will  not  cure. 

Curetting  means  scraping,  and  the  cavity  of  the  uterus 
may  be  scraped  for  endometritis,  mucous  polypus,  retained 
products  of  conception,  membranous  dysmenorrhea,  and 
to  obtain  a  piece  of  the  lining  membrane  for  microscopical 
examination. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — Those  for  dilatation  (p.  154),  and  in 
addition  a  blunt  flushing  curette  and  a  sharp  scoop. 


CURETTING  187 

Operation. — The  cervix  is  dilated  with  all  the  precau- 
tions mentioned  under  the  description  of  that  operation 
(p.  154).  The  extent  of  dilatation  depends  on  the  condition 
to  be  dealt  with.  If  digital  examination  of  the  uterine 
cavity  is  not  intended,  a  dilatation  up  to  No.  12  Fenton  will 
suffice. 

Before  pulling  out  the  last  dilator  the  operator  pro- 
poses to  employ,  the  douche  solution  that  is  being  used 
is  allowed  to  flow  through  the  curette  into  the  vagina  and 
round  the  cervix,  so  that  these  parts  may  be  rendered  as 
aseptic  as  possible  before  the  curette  is  introduced.  The 
dilator  is  then  withdrawn  and  the  curette  is  carefully 
inserted  through  the  cervical  canal  into  the  uterine  cavity, 
the  flow  of  the  douche  solution  being  temporarily  stopped. 
Opportunity  is  now  taken  carefully  to  sound  the  cavity 
in  order  to  ascertain  that  no  perforation  exists,  for  in  this 
event  the  introduction  of  an  injurious  chemical  solution 
into  the  peritoneal  cavity  will  convert  what  is  usually  only 
an  untoward  accident  into  a  serious  disaster.  A  solution 
of  biniodide  of  mercury,  1 — 4,000,  at  a  temperature  of 
1150  F.,  will  be  found  the  best  douche  to  use.  The  uterus 
being  steadied  by  the  volsella,  the  curette,  held  in  the 
operator's  right  hand,  is  passed  up  to  the  fundus  of  the 
uterus  (Fig.  106),  and  drawn  firmly,  evenly,  and  systemati- 
cally from  above  downwards  over  the  posterior  uterine  wall, 
then  over  the  anterior  wall,  and  then  laterally,  special 
attention  being  paid  to  the  two  cornua,  as  diseased  tissue 
in  this  situation  is  likely  to  be  missed.  Very  little  force 
is  to  be  used  ;  and  the  curettage  is  continued  until  a  grating, 
heard  or  felt,  indicates  that  the  musculature  is  reached. 
The  flushing  curette  is  now  laid  aside,  and  the  operator, 
taking  up  the  sharp  scoop,  vigorously  scrapes  the  wall 
of  the  cervical  canal  and  the  erosion  that  surrounds  the 
external  os  (Fig.  107). 

Where  no  evidence  of  corporeal  disease  is  present,  the 
mucosa  of  the  body  should  not  be  interfered  with,  and  the 
cervix  should  alone  be  treated. 


i88 


GYNECOLOGICAL  SURGERY 


Some  surgeons  conclude  the  operation  by  applying 
pure  carbolic  acid,  or  iodized  phenol  (carbolic  acid  3  parts, 
iodine  1  part),  to  the  denuded  surface  by  means  of  a  wool 


Fig.  106. — Curetting:    Applying 
the  curette. 


swab  on  a  Playfair's  probe  or  narrow-bladed  forceps.  It 
is  good  practice  in  gonorrhceal  and  frankly  septic  cases,  but 
is  not  necessary  in  all  cases. 


CURETTING 


189 


Dangers. — The  dangers  of  curetting  are  (i.)  sepsis, 
(ii.)  haemorrhage,  and  (iii.)  perforation  of  the  uterus. 

i.  Sepsis. — What  has  been  said  with  regard  to  sepsis 
(p.   167)   applies  here  also. 


Fig.   107. — Applying  the  sharp  spoon. 


ii.  Haemorrhage. — Sometimes  after  curetting  the  bleed- 
ing is  very  severe,  and,  if  not  dealt  with,  becomes  dangerous. 
Always  supposing  it  is  not  due  to  grave  laceration  of  the 
uterus,  it  can  best  be  arrested  by  packing  the  uterus  with 
sterile  gauze,  or  with  gauze  impregnated  with  iodoform  or 


igo 


GYNECOLOGICAL  SURGERY 


mercury,  as  the  operator  chooses  (Fig.  108).  If  no  gauze 
is  available,  the  effect  of  a  very  hot  douche,  1200  F.,  or  the 
application  of  iodized  phenol  or  carbolic  acid,  may  be  tried. 
It  sometimes  happens  that  severe  haemorrhage  will  take 
place  some  days  after  a  curetting,   and  if  so  it  must  be 


Fig.   108. — Packing  the  uterus  with  gauze. 


treated  on  similar  lines.  We  remember  a  case  in  which  on 
two  occasions,  the  eleventh  and  fourteenth  day  after  a 
simple  curetting,  the  patient,  who  had  convalesced  with 
a  perfectly  normal  temperature,  had  such  severe  and 
sudden  haemorrhage  that  on  both  occasions  she  nearly 
died.     No    cause   was   ever   discovered   for   this    complica- 


CURETTING  191 

tion,  but  it  was  probably  due  to  the  fact  that  the  uterine 
artery  had  been  wounded,  the  thrombus  at  the  site  of  the 
injury  becoming  detached  later. 

iii.  Perforation  of  the  uterus.  —  The  curette,  like  the 
dilator,  may  be  pushed  through  the  uterine  wall,  and  the 
uterine  wall  may  be  scraped  through  by  a  too  vigorous  use 
of  this  instrument.  The  operator  must  also  remember 
that  the  point  of  the  curette  may  catch  in  a  laceration  near 
the  internal  os,  and  that  such  a  laceration  may  be  curetted 
and  so  made  worse. 

Common  prudence,  and  the  knowledge  that  a  laceration 
may  be  present,  should  prevent  this  from  happening,  and 
if  a  laceration  has  not  been  felt  by  the  finger,  its  presence 
may  be  suspected  when,  instead  of  passing  in  smoothly, 
the  point  of  the  curette  catches  against  something  at  the 
internal  os  and  there  is  some  difficulty  in  getting  it  through 
that  orifice.  Great  care  should  be  taken  when  curetting 
a  uterus  in  which  carcinoma  of  the  body  is  suspected, 
especially  in  senile  cases,  for  in  such  the  wall  may  be  very 
thin  and  soft. 

The  results  and  treatment  of  perforation  are  dealt  with 
at  p.  162. 

Dressing  and  after-treatment. — See  Chapter  xxxn.  If 
the  uterus  has  been  plugged  the  gauze  must  be  removed 
in  twenty-four  hours.  The  patient  may  get  up  in  ten  to 
fourteen  days,  but  in  any  event  not  until  all  haemorrhagic 
discharge  has  ceased. 

RETAINED   PRODUCTS   OF   CONCEPTION 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — As  for  curetting  the  uterus  (p.  154). 

Operation. — The  steps  of  the  operation  are  the  follow- 
ing :— 

i.  Dilatation  of  the  cervix. — The  cervical  canal  is  dilated, 
in  the  manner  already  described  (p.  154),  until  the  index 
finger  can  be  introduced  into  the  uterine  cavity — i.e.  to 
No.  18  Fenton.     Before  the  last  dilator  in  use  is  removed, 


192 


GYNAECOLOGICAL  SURGERY 


the  vagina  and  cervix  are  well  douched  with  biniodide  of 
mercury,  1 — 4,000. 

ii.  Digital  examination. — Auvard's  speculum  is  removed, 
and    the    operator  having  re-dipped  his   right   hand  into 


Fig.  109. — Removal  of  retained  conceptional  products  : 
Digital    exploration  of  the  uterus. 

biniodide  of  mercury,  1 — 1,000,  the  dilator  and  volsella  are 
removed  by  the  assistant,  and  the  operator,  making  counter- 
pressure  with  the  left  hand  over  the  pubes,  passes  l\is 
first  finger  into  the  cavity  of  the  uterus  (Fig.  109).     If  the 


RETAINED  GONGEPTIONAL  PRODUCTS    193 

fundus  cannot  be  reached  in  this  way,  either  because  the 
uterus  is  retroverted  or  the  patient  very  fat,  the  volsella 
may  be  reapplied  to  the  cervix,  and  the  uterus  can  then 
be  pulled  down  over  the  finger  and  steadied  by  the 
assistant  during  the  exploration. 


Fig.  110. — Evacuation  of  the  uterus  with  the  ring  forceps. 

iii.  Removal  of  retained  products  with  finger  or  with 
ring  forceps. — Any  portions  of  placenta  or  membranes  that 
may  be  felt  are  now  detached  with  the  finger,  which  is 
then  withdrawn,  and,  the  ring  forceps  being  introduced, 
the  loose  pieces  are  removed  (Fig.  no).     The  finger  is  then 

N 


194  GYNECOLOGICAL  SURGERY 

introduced  again,  and  if  undetached  portions  are  still  felt, 
the  procedure  is  repeated. 

iv.  Curetting. — Authorities  differ  as  to  whether  the 
curette  should  be  used  after  the  retained  products  have 
been  removed  by  the  ring  forceps  or  the  finger.  It 
may  be  said  to  depend  upon  whether  the  miscarriage  or 
labour  has  quite  recently  taken  place  and  the  operation  is 
being  done  for  sepsis,  or  whether  it  has  occurred  some 
time  previously  and  the  operation  is  being  performed  for 
haemorrhage. 

If  for  recent  cases,  nearly  all  authorities  agree  that 
there  is  a  serious  danger  in  curetting,  because  innumerable 
lymph-channels  are  thus  opened  up  as  sites  for  infection. 
In  favour  of  this  contention  is  the  fact  that  serious  local 
lesions  such  as  peritonitis  or  cellulitis  often  appear  after 
curetting  in  such  cases  ;  and  the  records  of  many  deaths 
from  general  infection  could  now  be  collected. 

On  the  other  hand,  in  old-standing  cases  of  retained 
products  producing  haemorrhage,  and  associated  with  little 
or  no  sepsis,  the  operator  will  obtain  better  results  by 
using  the  curette.  For  the  method  of  curetting,  see 
p.  187. 

v.  Packing  the  uterus. — The  last  steps  in  the  opera- 
tion, whether  the  curette  is  used  or  is  not  used,  are  to 
douche  the  interior  of  the  uterus  with  biniodide  of  mer- 
cury, 1 — -4,000,  and  to  pack  the  uterine  cavity  with  gauze 
(Fig.  108)  for  twenty-four  hours,  as  free  oozing  is  likely  to 
occur.      If  sepsis  is  present,  iodoform  gauze  is  preferable. 

Dangers  and  difficulties. — The  dangers  and  difficulties 
are  those  discussed  under  the  heads  of  Dilatation  and 
Curetting. 

Dressing  and  after-treatment. — The  general  after- 
treatment  is  discussed  in  Chapter  xxxu.  If  the  uterus 
has  been  plugged,  the  gauze  is  removed  in  twenty-four 
hours  ;  and  if  the  haemorrhagic  discharge  has  ceased  and 
the  temperature  is  normal,  the  patient  gets  up  in  from 
ten  to  fourteen  days. 


MUCOUS  POLYPI  i95 

REMOVAL  OF  POLYPI,  MUCOUS,  MYOMATOUS,  OR 
PLACENTAL 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — The  instruments  required  will  depend 
upon  which  variety  of  polypus  is  being  treated.  In  any 
case  a  douche  apparatus,  a  Clover's  crutch,  an  Auvard's 
speculum,  scissors,  two  long  pressure-forceps,  a  volsella,  and 
a  sharp  spoon  will  be  required.  For  a  polypus  of  the  body, 
Fenton's  dilators,  a  curette,  an  additional  volsella,  a  uterine 
sound,  a  pair  of  ring  forceps,  two  curved  needles  No.  7, 
and  silk  No.  2.  For  a  myomatous  polypus  a  scalpel  may 
be  necessary. 

Mucous  Polypus  of  the  Cervix 

Operation. — The  vagina  is  douched  with  biniodide  of 
mercury,  1 — -4,000,  after  which  Auvard's  speculum  is  inserted. 
The  cervix  is  then  steadied  with  volsellae,  and  the  polypus 
seized  with  ring  forceps  and  slowly  twisted  off  (Fig.  111), 
after  which  in  all  cases  the  cervical  canal  should  be  scraped 
with  a  sharp  spoon,  since  the  polypus  is  only  a  localized 
expression  of  a  general  disease  of  the  mucosa  there. 

As  a  rule,  when  the  polypus  is  twisted  off  there  is  little 
or  no  bleeding,  but  if  there  is  more  oozing  from  the  stump 
than  the  operator  cares  to  leave,  the  stump  may  be  touched 
with  the  actual  cautery,  or  the  cervical  canal  may  be 
plugged  with  gauze. 

Mucous  Polypus  of  the  Body 

Operation. — If  when  operating  for  mucous  polypus  of 
the  cervix  the  uterus  is  found  to  be  enlarged,  it  is  always 
well  to  dilate  the  cervical  canal  and  make  a  digital  examina- 
tion to  ascertain  whether  there  are  any  polypi  in  the  uterine 
body.  There  need  not,  however,  be  polypi  in  the  body 
with  polypi  in  the  cervix ;  in  the  latter  case  it  will  be  the 
symptoms  that  have  suggested  the  presence  of  a  polypus, 
and  the   cervical   canal  must   be   dilated  in  order  that   a 


196 


GYNECOLOGICAL  SURGERY 


digital  examination  may  be  made  to  confirm  the  diagnosis. 
For  dilatation  of  the  cervix,  see  p.  154. 


Fig.   111. — Evulsion  of  a  mucous  polypus. 

Removal  of  the  polypus. — The  polypus  is  removed  by 
seizing  it  with  a  ring  forceps  and  twisting  it  off.  Although 
the    polypus    may   be    felt   with   the   finger,    the    operator 


REMOVAL  OF  POLYPI 


197 


may  not  be  successful  in  catching  it  with  the  forceps, 
in  which  case  the  polypus  may  be  scraped  off  in  the 
course  of  the  curettage  which  should  always  terminate  an 
operation  for  mucous  polypus  of  the  body,  since  this  con- 
dition is  merely  a  local  indication  of  the  general  disease  of 
the  endometrium.     For  the  method  of  doing  this  see  p.  187. 


Fig.  112. — Removal  of  a 

myomatous    polypus    by 

enucleation  :  Incising  the 

capsule. 


If  there  is  haemorrhage  and  it  cannot  be  arrested  by 
a  hot  intra-uterine  douche,  the  uterine  cavity  must  be 
plugged  with  gauze. 

Myomatous  Polypus  of  the  Cervix 

Operation The    polypus,    if    small,    is    seized    with    a 

volsella,  and  if  its  pedicle  is  thin  it  can  be  twisted  off  in 


198 


GYNAECOLOGICAL  SURGERY 


the  manner  already  described  for  a  mucous  polypus  (p.  195). 
If  too  thick  for  this,  the  pedicle  can  be  severed  by  the 
scissors.  No  haemorrhage  to  speak  of  will  result  in  either 
case,  the  muscular  portion  of  the  pedicle  contracting  round 
the  vessels  and  so  occluding  them. 


Fig.  113. — Reflecting  the 
capsule. 


The  polypus  may,  however,  be  so  large  that  the  pedicle 
cannot  be  reached,  in  which  case,  the  polyp  having 
been  seized  with  a  volsella,  its  capsule  should  be  incised 
(Fig.  112),  and  then  reflected  with  the  handle  of  a  scalpel 
(Fig.  113),  and  the  tumour  twisted  out  of  its  bed  (Fig.  114), 
pieces   of  it,   if  necessary,   being   cut   away   with   scissors, 


REMOVAL  OF  POLYPI 


199 


The  collapsed  capsule  is  then  twisted  round  to  torsion  the 
vessels,  and  cut  through  at  its  base  with  scissors  (Fig.  115). 
Occasionally,  enormous  myomatous  polypi  are  met 
with  entirely  filling  the  vagina.  These  must  be  dealt  with 
by  the  operation  of  morcellation,  to  be  presently  described. 


Fig.  114. — Enucleation 
of  the  tumour. 


Myomatous  Polypus  of  the  Body 

Methods. — The  exact  method  of  procedure  differs  in 
these  cases  according  to  the  condition  of  affairs  found  at 
the  operation. 

(a)  When  the  pedicle  can  be  reached. — -If  the  pedicle  is 
accessible,  the  removal  is  carried  out  in  the  same  way  as 
that  described  for  myomatous  polypus  of  the  cervix. 


200 


GYNECOLOGICAL  SURGERY 


(b)  When  the  polypus  has  not  dilated  the  cervical  canal. — 
If  the  cervical  canal  is  not  dilated,  then  the  presence  of 
the  polypus  is  only  an  assumption,  from  the  symptoms 
complained  of,  and  the  signs  discovered,  such  as  enlarge- 
ment of  the  uterus,  marked  relaxation  of  the  external  os, 
or  the  sensation  of  a  foreign  body  on  the  uterine  sound 


Fig.  115. — Treatment  of  the  pedicle. 

being  introduced.  The  cervix  must,  therefore,  be  dilated 
for  diagnostic  purposes  (p.  154),  and  the  polypus  dealt 
with  afterwards. 

(c)  When  the  polypus  is  dilating  the  cervical  canal. — 
In  this  case  it  is  of  the  greatest  importance  for  the  operator 
to  satisfy  himself  that  the  substance  presenting  is  a  fibroid 


REMOVAL  OF  POLYPI  201 

polypus  and  not  an  inverted  uterus.  On  occasion  this 
mistake  has  been  made,  and  an  inverted  uterus  has  been 
amputated.  The  operator  should  in  such  cases  make 
a  bimanual  examination  to  ascertain  whether  the  body 
of  the  uterus  is  in  its  normal  position,  or  is  absent.  If  the 
uterine  body  cannot  be  felt,  this  would  suggest  an  inversion, 
and  a  further  examination  may  reveal  a  "  cupping "  at 
the  fundus,  or  this  can  even  be  felt  more  easily  by  a  rectal 
examination.  The  uterine  sound  should  then  be  passed, 
and,  if  it  enters  more  than  the  normal  distance,  there  is 
sufficient  evidence  that  the  case  is  one  of  polypus.  If  the 
sound  enters  less  than  the  normal  distance,  this  suggests 
an  inversion.  The  operator  must  bear  in  mind,  however, 
that  the  point  of  the  sound  may  have  caught  against  the 
pedicle  of  the  polypus  at  the  point  of  its  attachment,  which, 
if  low  down,  would  prevent  the  instrument  from  passing 
to  the  top  of  the  uterus.  In  this  event  a  movement  of  the 
sound  would  free  it,  and  it  would  then  continue  its  advance. 
Rarely  the  polypus  may  be  inflamed  and  adherent  to  the 
cervical  canal  in  the  region  of  the  internal  os,  in  which 
case  the  sound  would  enter  only  a  very  little  way. 
Additional  signs  are  that  an  inverted  uterus  bleeds  easily 
on  being  touched,  whereas  a  myomatous  polypus  does  not  ; 
and  that  if  an  inversion  has  come  through  the  external 
os,  the  internal  openings  of  the  Fallopian  tubes  can  be 
seen. 

There  is  another  condition  which  may  simulate  a  myo- 
matous polypus,  and  that  is  a  submucous  myoma  which 
has  caused  a  certain  amount  of  uterine  inversion  and 
is  presenting.  A  careful  examination  on  the  above  lines 
will  reveal  the  identity  of  the  condition,  and  the  tumour 
must  be  enucleated  in  the  manner  presently  to  be  described 
(P-  203). 

Operation. — If  the  finger  can  be  introduced  by  the 
side  of  the  polypus  and  its  pedicle  felt,  it  may  be  removed 
by  seizing  it  with  a  volsella,  drawing  it  down,  and  then 
cutting  through  the  pedicle  with  scissors,  or,  if  this  is  not 


202  GYNECOLOGICAL  SURGERY 

possible,  by  first  enucleating  it  from  its  capsule  (p.  198), 
and  dealing  with  the  pedicle  afterwards. 

Excessive  size  of  the  polypus. — In  some  cases  the 
tumour  is  so  large  that  the  existence  of  a  pedicle  is  prob- 
lematical. Many  of  these  cases  turn  out  to  be  a  sessile 
submucous  myoma.  In  this  event  it  should  be  removed 
piecemeal,  i.e.  by  morcellation,  different  parts  of  the 
tumour  being  cut  away  with  scissors  until  the  pedicle,  if 
it  exists,  can  be  reached. 

Partial  inversion. — It  may  be  that  the  polypus,  when 
it  is  pulled  upon,  inverts  that  portion  of  the  uterus  to  which 
the  stump  is  attached,  so  that  the  operator  must  be  sure 
he  is  cutting  through  the  pedicle  and  not  in  reality  through 
the  inverted  piece  of  uterine  wall.  This  danger  is  avoided 
if  the  tumour  is  enucleated  before  dealing  with  the 
pedicle. 

Haemorrhage. — If  the  bleeding  does  not  stop  with  the 
administration  of  a  hot  intra-uterine  douche  the  uterine 
cavity  must  be  plugged  with  sterilized  gauze. 

Placental  Polypus 

In  this  case  a  piece  of  placenta  or  membrane  has  remained 
attached  to  the  uterus  and  has  become  partially  organized. 
The  treatment  of  the  condition  is  the  same  as  that  of  a 
mucous  polyp. 

Dressing  and  after-treatment  of  operations  for  polypi. 

— -When  the  polypus  has  been  removed  the  vagina  is 
douched  with  biniodide  of  mercury,  1 — 4,000,  and  tampons 
of  absorbent  wool  are  inserted  for  a  few  hours.  For  the 
after-treatment,  see  Chapter  xxxn.  After  the  removal  of 
cervical  polpyi  the  patient  may  get  up  in  two  or  three 
days,  in  fact,  when  the  haemorrhagic  discharge  has 
ceased.  Where  the  growth  is  corporeal  and  the  uterus 
has  been  dilated,  the  patient  must  stop  in  bed  for  ten 
days  to  a  fortnight.  In  these  cases  it  is  well  to  hasten  the 
retraction  of  the  uterus  by  the  administration  of  ergot. 


REMOVAL  OF  MYOMATA  203 

ENUCLEATION   OF    SUBMUCOUS   MYOMATA 

The  necessity  for  this  operation  will  be  discovered  on 
digital  examination  of  the  uterine  cavity,  made  for  purposes 
of  diagnosis. 

Limitation. — Enucleation  of  a  submucous  myoma  should 
only  be  attempted  when  the  meridian  of  the  tumour  is 
free  in  the  uterine  cavity,  when  the  tumour  is  not  larger 
than  a  Tangerine  orange,  and  when  it  is  apparently  the 
only  myoma  of  any  size  in  the  uterus.  By  this  last  state- 
ment it  is  not  meant  to  exclude  cases  where  there  are  two 
small  submucous  tumours,  but  when  interstitial  or  sub- 
peritoneal tumours  can  be  felt  it  is  a  much  more  satisfactory 
and  safe  procedure  to  perform  hysterectomy. 

Preparation  of  the  patient. — See  pp.  78-82. 

Instruments. — -Douche  apparatus,  Clover's  crutch, 
Auvard's  speculum,  two  volsellae,  Fenton's  dilators,  scal- 
pel, scissors,  four  pairs  of  long  pressure-forceps,  ring  forceps, 
curved  needle  No.  7,  silk  Nos.  2  and  4. 

Operation. — i.  Dilatation  of  the  cervix  (p.  154)  is  the 
first  step  in  the  operation. 

ii.  Incision  of  mucous  membrane. — The  index  finger 
of  the  left  hand  is  passed  into  the  uterine  cavity  and  the 
relations  of  the  tumour  are  examined.  With  the  scalpel  or 
scissors  passed  along  the  index  finger  an  incision  in  the 
mucous  membrane  covering  the  tumour  is  made  sufficiently 
deeply  to  penetrate  the  capsule  and  large  enough  to  allow 
the  point  of  the  finger  to  pass  in. 

iii.  Enucleation  from  the  capsule. — -The  index  finger  of 
the  left  or  the  right  hand,  whichever  is  the  more  convenient, 
is  then  pushed  through  the  hole  in  the  capsule  and  the 
tumour  is  enucleated  from  its  capsule,  the  remaining  hand 
pressing  down  the  uterus  from  the  abdomen  to  steady  it 
and  bring  the  growth  more  into  reach.  As  a  rule,  the 
tumour  will  be  easily  enucleated.  When  free,  it  must  be 
seized  with  a  volsella,  or,  if  small,  with  a  ring  forceps,  and 
gradually  delivered  through  the  cervix. 


2o4  GYNAECOLOGICAL  SURGERY 

Difficulties,  i.  Adherent  capsule. — Sometimes  it  is  not 
so  easy  to  enucleate  the  tumour  from  its  bed  with  the 
finger,  and  in  these  cases  the  myoma  should  be  seized  with 
a  volsella,  by  means  of  which  the  tumour  can  be  twisted 
in  various  directions,  while  the  finger  tries  to  free  it,  helped 
perhaps  now  and  again  by  a  few  careful  snips  with  the 
scissors. 

ii.  Excessive  size. — Roughly  speaking,  a  myoma  the 
size  of  a  Tangerine  orange  can  be  delivered  through  a  fully 
dilated  cervix.  If  the  tumour  is  larger  than  this,  the  operator 
may  be  able  to  deliver  it  by  incising  the  cervix  on  each 
side  up  to  the  vaginal  vault,  or  more  room  may  even  be 
obtained  by  pushing  the  bladder  off  the  uterus  and 
then  incising  the  cervix  and  the  anterior  surface  of  the 
uterus  as  high  as  the  peritoneal  reflection.  If,  in  spite 
of  this  incision,  or  preferably  before  its  employment,  the 
tumour  is  found  to  be  too  large  to  deliver  whole,  it  must 
be  cut  up  and  removed  in  small  pieces  (morcellation). 
Myomata  up  to  the  size  of  an  orange  may  be  removed  in 
this  way ;  but  if  larger,  hysterectomy  should  be  performed 
in  the  first  instance. 

iii.  Adeno-myomata. — These  tumours  are  usually  sub- 
mucous, and  cannot  from  the  symptoms  or  feel  be  dis- 
tinguished from  pure  myomata.  They  are  never  truly 
encapsuled,  however,  and  hence  attempts  to  enucleate 
them  in  mistake  for  a  submucous  myoma  always  fail. 

Dangers,  i.  Incomplete  removal. — It  occasionally  hap- 
pens that  the  operator  misjudges  the  size  of  the  tumour 
he  sets  out  to  remove,  and,  after  tearing  away  several 
pieces  of  it,  finds  that  he  cannot  finish  the  enucleation, 
whilst  some  myomata  and  all  adeno-myomata  have  no 
capsule  and  cannot  be  enucleated.  The  dangers  that  may 
accrue  from  this  unsuccessful  effort  are  haemorrhage  and 
sepsis.  We  have  seen  a  case  where  bleeding  came  on  so 
profusely  half  an  hour  after  a  partial  enucleation  that  the 
patient  was  only  saved  by  an  immediate  hysterectomy. 
Sepsis  is  brought  about  by  the  remaining  portion  of  the 


ENUCLEATION  OF  MYOMATA  205 

fibroid  sloughing  out,  during  the  process  of  which  the 
patient  may  die,  or  be  dangerously  ill  for  many  weeks. 

The  only  course,  if  enucleation  prove  a  failure,  is  imme- 
diate hysterectomy. 

ii.  Haemorrhage. — As  a  rule,  there  is  no  haemorrhage 
to  speak  of.  If  it  is  a  cervical  myoma  that  has  been 
enucleated,  the  bleeding  may  be  serious  from  damage  to 
the  uterine  arteries.  The  treatment  for  bleeding  that  a 
hot  uterine  douche  will  not  stop  is  to  pack  the  uterus 
with  gauze,  and,  this  failing,  to  perform  hysterectomy. 

iii.  Sepsis. — Apart  from  a  portion  of  the  tumour  being 
left  behind,  the  patient  may  be  infected  by  dirty  instru- 
ments or  hands,  or  the  myoma  may  be  already  septic  before 
the  operation.  The  first  source  of  danger  is  to  be  obviated 
by  strict  asepsis  and  antisepsis  prior  to,  during,  and  after 
the  operation,  and,  in  the  case  of  tumours  already  infected, 
by  performing  the  operation  with  as  little  laceration  of 
the  healthy  tissues  as  may  be  possible,  and  subsequently 
irrigating  the  uterus  thoroughly  and  packing  its  cavity 
with  iodoform  gauze. 

iv.  Perforation  of  the  uterus. — The  uterus  may  be 
perforated  by  a  too  vigorous  use  of  the  finger  or  of  the 
scissors  during  separation  of  the  capsule,  the  operator 
failing  to  appreciate  the  fact  that  the  tumour  reaches 
almost  up  to  the  peritoneal  covering  of  the  uterus.  Again, 
when  the  tumour  is  being  removed  by  morcellation,  the 
operator  may  incise  the  muscle-wall  with  the  scissors  in 
mistake  for  the  tumour.  If  the  cavity  of  the  uterus  is 
clean  when  the  accident  occurs,  no  ill  results  may  follow, 
and,  unless  the  rent  is  large  or  the  haemorrhage  free, 
the  uterus  after  the  removal  of  the  tumour  should  be 
packed  with  gauze  and  the  case  watched.  If,  however,  a 
sloughing  myoma  is  being  dealt  with,  or  the  rent  is  large, 
or  a  piece  of  bowel  comes  through  the  rent,  it  is  better 
to  perform  vaginal  hysterectomy  after  removing  the 
tumour. 

Dressing   and   after  -  treatment.  —  See    Chapter    xxxn. 


206 


GYNECOLOGICAL   SURGERY 


The  patient  can  get  up  on  the  fourteenth  day  if  all  haemor- 
rhagic  discharge  has  stopped. 

Removal  of  a  Large  Submucous  Myoma  by 
morcellation 
Occasionally   a  submucous  myoma  is  so   large   that   it 
dilates  the  cervical  canal  and  gradually  fills  the  vagina. 


Fig.   116. — Morcellation  of  a  submucous  myoma :    Gutting 
away  the  lower  pole  of  the  tumour. 

These  cases  differ  from  large  myomatous  polypi  inasmuch 
as  they  are  attached  to  the  uterus  by  a  very  broad  base 
and  not,  as  in  the  case  of  polypi,  by  a  pedicle. 
Preparation  of  the  patient. — See  pp.  78-82. 


ENUCLEATION  OF  MYOMATA 


207 


Instruments. — Clover's  crutch,  Auvard's  speculum,  scal- 
pel, scissors,  douche  apparatus,  four  pairs  of  long  pressure- 
forceps,  ring  forceps,  two  volsellae,  two  curved  needles 
No.  7,  silk  Nos.  2  and  4. 

Operation. — The  steps  of  the  operation  are  the  following  : 
i.  Incising    the    capsule. — The    tumour   is   seized    with 


Fig.   117. — Reflecting  the  capsule. 

the  volsellae,  drawn  down,  and  its  lower  pole  cut  away,  by 
which  means  the  edge  of  the  capsule  is  exposed  (Fig.  116). 
ii.  Enucleating  the  tumour. — The  tumour  is  now  gra- 
dually enucleated,  being  pulled  down  with  a  volsella  held 
in  the  left  hand,  while  the  forefinger  of  the  right  hand 
reflects  the  capsule  (Fig.  117). 


208 


GYNAECOLOGICAL  SURGERY 


iii.  Removing  the   tumour. — After  a  sufficient   amount 
of  the  tumour  has  been  stripped  of  its  capsule,  as  much 


Fig.  118. — Continued  removal  of  the  tumour. 


of  the  denuded  portion  as  possible  is  removed  with  a  pair 
of  scissors  (Fig.  118).  The  volsella  is  then  passed  up 
into  the  uterine  cavity,  but  inside  the  capsule,  and  the  re- 
mains of  the  tumour  are  seized  and  pulled  upon,  while  with 


ENUCLEATION  OF  MYOMATA 


209 


the    other    hand    the    surgeon   continues   the   enucleation, 
assisting  it  by  a  certain  amount  of  lateral  and  rotatory 


Fig.   119. — Seizing  the  upper  part 
of  the  tumour. 


traction  of  the  volsella  (Fig.  119),  so  that  at  last  the 
upper  pole  of  the  tumour  is  shelled  out  and  delivered 
(Fig.  120). 

iv.  Treatment    of    the    capsule. — The   capsule    is    now 
O 


210 


GYNAECOLOGICAL  SURGERY 


seized,  pulled  down  with  a  pair  of  ring  forceps,  and  cut 
off  as  near  the  uterine  wall  as  possible  (Fig.  121). 


Fig.  120. — Enucleation 

of  the  upper  pole  of 

the  tumour. 


An  alternative  method  of  treating  the  capsule  would 
be  to  pass  a  ligature  round  it  before  its  division,  but  as 


ENUCLEATION  OF  MYOMATA 


211 


a  rule  there  is  no  bleeding,  and  if  there  is,  this  can    be 
arrested  by  packing  the  uterus. 

Dangers. — The  uterine  wall  may  be  perforated  during 
the  enucleation,  or  the  operator  may  have  misjudged  the 


Fig.    121. — Treatment  of  the   capsule. 

condition  and  be  unable  to  remove  all  the  tumour  ;  in 
either  case  the  treatment  to  be  followed  is  that  described 
at  p.  204. 

Dressing  and  after-treatment.  —  See  Chapter  xxxn. 
The  patient  gets  up  on  the  fourteenth  day,  if  all  discharge 
has  ceased. 


CHAPTER    X 


HYSTERECTOMY;    GENERAL    CONSIDERATIONS 

I.     INDICATIONS    FOR    HYSTERECTOMY 

The  uterus  is  usually  removed  for  conditions  affecting  the 
organ  itself,  but  occasionally  its  removal  becomes  a  matter 
of  necessity  in  the  course  of  an  operation  for  tubal  or 
ovarian  disease  or  for  large  tumours  of  the  broad  ligament, 
in  order  that  the  object  of  the  operation  may  be  attained. 
The  conditions  affecting  the  uterus  for  which  its 
removal  may  be  indicated  are — 


Injuries 
Inflammation 


New  growths' 


4.  Congenital  defects 


5.  Acquired  defects 


Rupture. 

Acute  sepsis,  chronic  sepsis,  fibro- 
sis, senile  endometritis,  tuber- 
cular endometritis. 

Myoma,  adeno  -  myoma,  carci- 
noma, sarcoma,  chorion-epi- 
thelioma, hydatid  disease, 
villous  papilloma. 

Haematometra,  pregnancy  in  an 
undeveloped  horn  of  the 
uterus. 

Dysmenorrhea,  inversion,  haema- 
tometra, haemorrhage  apart 
from  inflammation  or  new 
growth. 

1.  Injuries,  i.  Obstetrical.  —  Rupture  of  the  uterus 
during  labour  may  be  an  indication  for  hysterectomy.  The 
advantage  of  the  operation  is  that  it  removes  the  damaged 
organ  and  prevents  any  further  haemorrhage  and  subsequent 
risk  of  intra-uterine  sepsis.    Its  disadvantages  are — 

212 


HYSTERECTOMY:    INDICATIONS  213 

(a)  The  sacrifice  of  the  organ. 

(b)  That  many  patients  in  whom  the  disaster  has 
occurred  are  already  so  collapsed  that  a  radical  operation 
of  this  nature  is  unable  to  be  borne. 

(c)  The  surroundings  under  which  the  operation  might 
have  to  be  carried  out  may  be  unfavourable  to  its  success. 

Extraperitoneal  tears  and  small  intraperitoneal  tears 
through  the  fundus,  without  persistent  prolapse  of  bowel 
or  omentum,  can  usually  be  treated  successfully  by  plug- 
ging the  rent  with  gauze  ;  whilst  large  transverse  tears,  with 
deficient  retraction  of  the  uterine  muscle  and  profuse 
external  haemorrhage,  or  cases  in  which  bowel  or  omentum 
persistently  prolapses  or  in  which  it  is  certain  that  severe 
intraperitoneal  bleeding  is  taking  place,  should  be  imme- 
diately operated  upon,  and  if  the  tear  cannot  be  satis- 
factorily sutured  the  uterus  should  be  removed. 

ii.  Operative  injuries. — This  subject  will  be  found 
fully  discussed  in  connexion  with  the  dangers  of  dilatation 
and  curettage  of  the  uterus  (pp.  160-68). 

iii.  Accidental  injuries. — Most  of  these  injuries  occur 
to  the  pregnant  woman.  If  the  uterus  is  septic  before  the 
surgeon  sees  the  patient,  as  when  the  perforation  has 
occurred  in  the  course  of  an  attempted  criminal  abortion, 
it  is  sometimes  necessary  to  remove  the  damaged  organ. 
If  the  patient  is  seen  soon  after  the  uterus  has  been  injured, 
as,  for  example,  in  gunshot  wounds  or  goring  by  cattle, 
the  same  treatment  may  be  necessary,  or  the  rent  may 
be  sutured  after  the  removal  of  products  of  gestation. 

2.  Inflammation. — -The  uterus  has  been  removed  for 
acute  puerperal  sepsis.  The  results  are,  however,  disas- 
trous, and  we  are  of  opinion  that,  if  any  operative  treatment 
is  to  be  undertaken  in  such  conditions,  drainage  of  the 
pelvis  through  multiple  incisions  gives  the  best  chance  of 
success.  If,  however,  on  the  abdomen  being  opened,  the 
uterine  wall  is  found  to  be  the  seat  of  abscess  formation, 
the  organ  must  be  removed. 

The  removal  of  the  uterus  is  sometimes  indicated  in 


2i4  GYNAECOLOGICAL  SURGERY 

chronic  septic  infection  of  its  interior,  usually  gonococcal, 
the  symptoms  of  which,  a  persistent  excoriating  discharge 
and  profuse  haemorrhage,  have  defied  all  other  methods 
of  treatment.  Most  of  these  cases  have  already  had  both 
appendages  removed  for  pyo-salpinx. 

There  is  a  group  of  cases  exhibiting  most  profuse  menor- 
rhagia  in  which  the  symptoms  are  due  to  a  diffuse  fibrotic 
degeneration  affecting  the  whole  thickness  of  the  uterine 
wall.  Should  repeated  curettage  fail  to  relieve  these  cases, 
the  uterus  should  be  removed,  or  utriculoplasty  performed. 
Hysterectomy  is  occasionally  done  for  senile  endometritis 
in  which  life  is  menaced  by  the  presence  of  a  pyometra 
that  cannot  be  cured  by  dilatation  and  curettage. 

Tubercular  endometritis  is  a  rare  disease,  and  its 
symptoms  are  frequently  mistaken  for  those  of  carcinoma 
of  the  uterus.  When  the  nature  of  the  condition  is  made 
clear  by  proper  examination,  the  uterus  should  be  removed, 
in  the  absence  of  symptoms  of  generalized  tuberculosis. 

3.  New  growths,  i.  Myoma,  adeno-myoma. — Hyster- 
ectomy as  a  treatment  for  these  cases  may  be  a  matter 
either  of  necessity  or  of  expediency. 

Where  the  tumour  is  endangering  the  patient's  life  from 
haemorrhage,  pressure,  or  infection,  its  removal  is  abso- 
lutely necessary.  If,  again,  the  symptoms,  while  not 
directly  endangering  life,  prevent  the  patient  from  earning 
her  living,  hysterectomy  is  practically  a  necessity. 

If  the  symptoms  are  in  any  way  affecting  the  patient's 
health,  or  seriously  interfering  with  her  comfort  or  social 
occupation,  in  our  opinion  the  removal  of  the  tumour  is 
expedient.  For  the  operation,  when  carried  out  by  skilled 
hands  on  patients  whose  general  health  has  not  been  seriously 
deteriorated  by  prolonged  bleeding,  auto-intoxication,  pres- 
sure, or  pain,  is  attended  with  a  mortality  not  greater  than 
that  following  the  removal  of  a  chronically  inflamed 
appendix,  that  is  to  say,  less  than  1  per  cent.  Indeed,  the 
only  unavoidable  causes  of  death,  as  far  as  the  surgeon 
is  concerned,  are  pulmonary  embolism  and  the  anaesthetic. 


HYSTERECTOMY:    INDICATIONS  215 

If,  however,  the  health  of  the  patient  has  been  under- 
mined by  any  of  the  above-mentioned  causes,  the  operation 
becomes  one  of  much  greater  gravity. 

When  watching  a  formidable  hysterectomy  upon  a  pa- 
tient exsanguinated  from  prolonged  bleeding  and  emaciated 
from  prolonged  endurance  of  pain  and  toxic  absorption, 
it  is  melancholy  to  reflect  that  there  was  a  time  when  the 
tumour  could  have  been  removed  with  perfect  ease  and 
almost  certain  success.  A  grave  responsibility  rests  upon 
those  who  aid  and  abet  the  natural  inclination  of  patients 
to  postpone  operative  procedure  until  their  lives  become 
a  misery.  It  is  a  curious  psychological  fact  that  many 
medical  men  of  undoubted  eminence  in  their  profession 
will  without  the  least  hesitation  sanction  or  urge  the  removal 
of  so  essential  an  organ  as  the  ovary,  while  they  look  askance 
at  the  extirpation  of  one  which,  having  become  unfitted  for 
its  function  of  child-bearing,  is  merely  a  menacing  encum- 
brance. To  tell  a  woman  suffering  from  uterine  myoma 
that  the  removal  of  her  uterus  will  subject  her  to  the  risk 
of  madness,  of  alteration  in  her  nature  and  sexual  feelings, 
or  of  unfaithfulness  on  the  part  of  her  husband,  is,  in 
our  opinion,  reprehensible.  A  woman  whose  myomatous 
uterus  has  been  removed  by  hysterectomy  is,  except  in 
regard  to  child-bearing,  at  no  disadvantage  compared  with 
her  former  condition.  And,  seeing  that  the  majority  of 
women  suffering  from  myomata  have  passed  the  common 
age  for  child-bearing  and  that  the  presence  of  the  tumour 
renders  the  occurrence  of  pregnancy  unlikely,  this  dis- 
advantage  is   a  very  small   one. 

ii.  Malignant  disease. — Hysterectomy  for  malignant 
disease,  if  the  operation  be  possible,  is  an  obvious  course. 
Further  discussion  of  this  point  will  be  found  in  the  chapter 
for  radical  operation  for  carcinoma  of  the  cervix  (p.  361). 

iii.  Other  new  growths. — All  other  new  growths  of 
the  uterus  are  extremely  uncommon.  Rarely,  villous  papil- 
lomata  are  met  with  springing  from  the  endometrium. 
The  nature  of  these  tumours  and  their  relation  to  carcinoma 


216  GYNECOLOGICAL  SURGERY 

are  so  little  known  that  the  safest  course  is  to  treat  them 
as  though  they  were  malignant  and  extirpate  the  uterus. 
Hysterectomy  has  also  had  to  be  carried  out  for  echino- 
coccus  cysts  of  the  uterus. 

4.  Congenital  defects. — There  are  certain  congenital 
defects  of  the  genital  tract  which  may  result  in  conditions 
that  necessitate  the  removal  of  the  uterus  ;  the  most 
common  example  of  these  being  a  hsematometra  dependent 
on  absence  of  the  vagina  in  whole  or  in  part.  In  some  cases 
the  making  of  an  artificial  vagina  has  remedied  the  condition 
(p.  129).  More  commonly,  however,  such  plastic  surgery 
is  impossible  or  unsatisfactory  and  the  uterus  has  to  be 
removed.  Occasionally  one  meets  with  cases  of  hsemato- 
metra in  one  half  of  a  double  uterus,  whilst  rarely  pregnancy 
may  occur  there.  In  either  case  removal  of  the  malformed 
half  of  the  uterus  will  be  necessary. 

5.  Acquired  defects. — Hysterectomy  is  sometimes  indi- 
cated to  stop  the  periods  in  cases  of  intractable  dysmenor- 
rhcea  disabling  the  patient,  and  also  in  cases  of  uterine 
haemorrhage  which  is  threatening  life  and  for  which  no 
definite  cause  can  be  found.  Chronic  inversion  of  the  uterus 
has  been  treated  successfully  by  hysterectomy,  other 
methods  having  failed.  Finally,  removal  of  the  uterus  may 
be  indicated  as  the  remedy  for  some  artificially  acquired 
stenosis  of  the  genital  canal  producing  haematometra.  The 
most  common  cause  of  this  is  scar-contraction  after  high 
amputation  of  the  cervix. 

The  conditions  affecting  the  Fallopian  tube  for  which 
hysterectomy  may  be  indicated  are — 

1.  Tubal  gestation. — There  are  three  sets  of  circum- 
stances under  which  the  uterus  may  have  to  be  removed 
for  this  disease.  (1)  The  gestation  sac  may  be  so  adherent 
to  the  back  of  the  uterus  that  the  bleeding  due  to  its 
removal  cannot  be  controlled  by  any  other  method.  (2)  In 
cases  of  interstitial  pregnancy  the  uterine  wall  may  be  so 
destroyed  that  it  is  impossible  to  conserve  the  organ. 
(3)  In  advanced  cases  of  secondary  intraperitoneal  or  intra- 


HYSTERECTOMY:    INDICATIONS  217 

ligamentous  gestation  the  placenta  is  almost  certain  to  be 
more  or  less  attached  to  the  surface  of  the  uterus,  which 
organ  may  have  to  be  removed  to  control  the  haemorrhage 
due  to  its  separation. 

2.  Salpingitis. — It  is  maintained  by  many  Continental 
authorities  that  in  bilateral  salpingo-oophorectomy  or 
salpingectomy  the  uterus  should  be  removed,  for  they 
argue  that  it  is  of  no  further  use,  and  that  it  may  become 
a  source  of  trouble  from  haemorrhage  and  discharge  or  of 
danger  from  cancer.  Our  practice  has  not  been  of  this 
radical  nature  ;  we  limit  the  removal  of  the  uterus  to- 
gether with  the  appendages  to  certain  cases  of  salpingitis 
where  it  is  necessary  to  remove  it  in  order  to  control 
haemorrhage,  where,  from  the  size  and  softness  of  the 
uterus,  acute  metritis  is  obvious,  and  where,  by  reason 
of  adhesions,  a  more  satisfactory,  operation  is  thus  effected. 

There  can  be  no  doubt  that  the  removal  of  the  uterus 
for  acute  suppurative  pelvic  inflammation  adds  an  appre- 
ciable risk  to  what  is  already  a  very  dangerous  operation. 
The  advantage  of  vaginal  drainage  has  been  urged  as  a 
reason  for  its  performance,  but  we  would  refer  the  reader 
to  the  remarks  upon  this  subject  at  p.  47. 

3.  Carcinoma  of  the  tube. — This  rare  condition  is  only 
adequately  treated  by  removing  the  uterus  in  addition 
to  the  diseased  structures. 

The  conditions  affecting  the  ovary  for  which  removal 
of  the  uterus  may  be  indicated  are  — ■ 

1.  Ovarian  cysts  and  tumours. — Hysterectomy  should 
be  performed  in  addition  to  bilateral  salpingo-oophorectomy 
in  all  cases  where  the  ovary  is  the  seat  of  operable  malig- 
nant disease.  An  ovarian  cyst  may  be  so  adherent  to  the 
uterus  that  its  separation  is  impossible,  and  in  this  case 
the  uterus  will  have  to  be  removed  with  the  tumour. 

2.  Ovarian  abscess. — The  remarks  above,  bearing  upon 
salpingitis,  are  equally  applicable  to  this  condition. 

The  conditions  affecting  the  broad  ligament  for  which 
removal  of  the  uterus  may  be  indicated  are — 


218  GYNECOLOGICAL  SURGERY 

Cysts  and  myomata. — It  not  infrequently  happens  that, 
in  order  to  effect  the  removal  of  a  cyst  of  the  broad  liga- 
ment, it  is  a  necessity  to  remove  the  uterus,  from  which 
it  cannot  be  separated  ;  whilst  with  a  myoma  of  the 
broad  ligament  the  removal  of  the  uterus  is  usually  an 
essential  part   of   the   operation. 

II.   COMPARATIVE   ADVANTAGES   OF   SUBTOTAL 
AND   TOTAL   HYSTERECTOMY 

The  circumstances  in  which  it  may  be  proper  to  remove 
the  entire  uterus  are  malignant  disease,  tubercular  endo- 
metritis, sepsis  in  all  its  forms,  hydatid  disease,  villous 
papilloma  of  the  endometrium,  inversion,  acquired  haema- 
tometra,  certain  forms  of  congenital  haematometra,  and 
myomata  with  co-existent  cervicitis. 

For  all  other  conditions  requiring  hysterectomy  the 
removal  of  the  body  alone  will  be  found  sufficient,  and,  in 
our  opinion,  is  the  best.  This,  however,  is  not  in  accordance 
with  the  views  of  all  surgeons.  It  will  therefore  be  profit- 
able at  this  point  to  discuss  the  relative  merits  of  the  total 
and  subtotal  operations  respectively. 

Those  who  practise  the  total  operation  in  every  case 
requiring  hysterectomy  argue  that  this  method  is  the  best 
because — 

i.  Better  drainage  of  the  operation-site  is  secured. 

2.  The  cervical  stump  may  become  septic  as  a  result 

of  the  operation. 

3.  The  uterus  may  be  the  seat  of  malignant  disease 

at  the  time  of  the  operation,  though  not  so  diag- 
nosed. 

4.  The   conserved   cervix   is   useless,    and   may  subse- 

quently become  the  seat  of  malignant  or  inflam- 
matory disease. 

5.  This    advantage   is   gained   and   these   dangers   are 

avoided  without  any  increase  in  operative  diffi- 
culty and  mortality  or  subsequent  liability  to 
interference  with  the  marital  function. 


HYSTERECTOMY:  SUBTOTAL  AND  TOTAL   219 

The  counter-arguments  by  which  the  advocates  of  sub- 
total hysterectomy  maintain  the  correctness  of  their 
position  may  conveniently  be  dealt  with  in  the  same 
order,  as  follows  : — 

1.  Better  drainage. — The  objects  of  drainage  in  a  sur- 
gical operation  are  twofold — (1)  to  allow  of  the  escape  of 
discharges  already  septic,  (2)  to  permit  of  the  free  escape 
of  an  anticipated  collection  of  blood  or  serum  which  if 
retained  might  become  infected. 

We  have  already  stated  that  if  the  uterus  is  infected, 
it  should  be  removed  entire.  If  the  operation  of  subtotal 
hysterectomy  has  been  efficiently  performed,  no  collection 
of  blood  or  serum  should  occur,  and  therefore,  in  what 
we  may  term  clean  cases,  the  increased  freedom  of  drainage 
conferred  by  total  hysterectomy  is  not  only  unnecessary 
but  is  actually  harmful,  in  that  it  brings  the  operation 
area  into  direct  continuity  with  a  surface  (the  vagina) 
which  is  never  sterile. 

2.  Septic  stump. — That  the  stump  may  become  septic 
in  subtotal  hysterectomy  is  true,  but  this  is  due  to  lack  of 
asepsis  in  the  technique  and  not  to  the  kind  of  operation 
performed,  for  the  amputation  occurs  across  a  portion  of 
the  genital  canal  which  is  normally  sterile.  In  total 
hysterectomy,  on  the  other  hand,  more  or  less  infection 
of  the  operation  area  always  occurs,  some  of  the  ligatures 
almost  invariably  being  separated  per  vaginam.  That  the 
operators  themselves  recognize  this  is  evidenced  by  the 
fact  that  they  always  leave  the  vagina  open. 

3.  Presence  of  undiagnosed  carcinoma. — Occasionally 
it  has  happened  that  the  body  of  the  uterus,  having  been 
amputated,  is  found  when  opened  to  be  the  seat  of  un- 
diagnosed malignant  disease.  More  rarely  the  conserved 
cervix  has  at  the  time  of  operation  been  the  seat  of  un- 
recognised carcinoma.  The  first  disaster  may  be  minimized 
by  the  habit  of  carefully  examining  the  body  of  the  uterus 
directly  it  is  removed,  and,  in  the  event  of  malignant  disease 
being  found,  forthwith   extirpating  the   remainder   of   the 


220  GYNECOLOGICAL  SURGERY 

organ.  The  second  disaster  is  very  uncommon  indeed. 
In  the  hands  of  careful  surgeons,  both  occur  very  rarely ; 
but  nevertheless  these  possible  complications  are  undeni- 
able drawbacks  to  subtotal  hysterectomy. 

4.  The  cervix  is  useless  and  liable  to  disease. — The 
cervix  is  not  useless.  The  secretion  of  its  glands  is  an 
important  lubricant  to  the  vagina. 

After  the  removal  of  the  cervix  a  scar  is  left  across 
the  roof  of  the  vagina,  which  for  some  time  at  all  events, 
and  in  many  cases  for  at  least  a  year,  is  the  seat  of  tender 
granulation-tissue  and  gives  rise  to  a  troublesome  discharge 
until  a  ligature  or  ligatures  become  separated.  When 
healing  eventually  occurs,  there  is  a  tendency  for  the 
vaginal  vault  to  become  puckered  and  constricted.  Further- 
more, the  ovaries,  if  they  have  been  conserved,  or  the 
intestine  or  bladder,  may  become  adherent  to  the  line  of 
peritoneal  suture  overlying  the  vagina.  Any  of  these 
sequeke  may  be  the  cause  of  dyspareunia. 

On  the  other  hand,  the  conservation  of  the  cervix 
maintains  the  integrity  of  the  vaginal  vault,  and,  though 
the  structures  mentioned  may  become  adherent  to  the 
suture-line  across  the  cervix,  yet  in  this  case  the  cervical 
stump  intervenes  between  them  and  the  vaginal  roof. 

Subtotal  hysterectomy  is  most  often  performed  for 
uterine  myomata,  and  it  is  in  the  discussion  of  the  operative 
treatment  of  this  disease  that  such  great  divergence  of 
opinion  has  chiefly  occurred.  Statistics  show  that  carcinoma 
of  the  cervix  is  very  unlikely  to  affect  a  woman  whose 
uterus  has  been  removed  for  myomata,  apparently  because 
the  invariable  antecedent  of  the  former  disease  is  a  chronic 
cervicitis  initiated  at  the  time  of  child-birth,  whilst  myo- 
mata are  a  cause  of  sterility.  The  fact  remains,  how- 
ever, that  carcinoma  does  sometimes  subsequently  affect 
a  cervix  left  after  subtotal  hysterectomy ;  and  if  this  were 
the  only  thing  to  be  considered,  we  should  unhesitatingly 
support  the  removal  of  the  cervix  in  all  cases. 

5.  Operative  mortality  and  morbidity. — Whilst    admit- 


HYSTERECTOMY :  SUBTOTAL  AND  TOTAL  221 

ting  certain  of  the  points  claimed  for  total  hysterectomy 
as  a  routine  method,  the  question  remains  whether  these 
advantages  are  not  too  dearly  bought  by  the  increased 
risk  of  the  operation  as  regards  mortality  and  morbidity 
when  compared  with  the  results  of  the  subtotal  method 
in  suitable  cases. 

There  is  no  doubt  that  the  subtotal  method  is  always 
the  easier,  and  sometimes  very  much  the  easier,  and  con- 
sequently the  operation  is  performed  in  less  time  and 
with  a  diminished  chance  of  injury  to  the  important 
structures  adjacent  to  the  uterus.  In  our  own  hands  an 
average  straightforward  total  hysterectomy  takes,  under  fa- 
vourable conditions,  from  thirty-five  to  forty-five  minutes 
to  perform,  whereas  by  the  subtotal  method  we  complete 
the  operation  well  within  thirty  minutes  ;  and  we  believe 
this  to  be  the  experience  of  others  versed  in  this  class 
of  work. 

The  increased  risk  of  injury  to  the  bladder,  bowel,  or 
ureters  in  total  hysterectomy  is  obvious  from  anatomical 
considerations,  \nd  is  considerably  enhanced  in  certain 
circumstances,  such  as  great  depth  of  the  pelvis,  marked 
obesity,  and  abnormal  fixity  of  the  uterus.  In  the  hands 
of  experts  such  accidents  are  of  rare  occurrence,  but  it  is 
none  the  less  true  that  injuries  to  the  bladder,  bowel,  and 
ureter  are  much  commoner  in  total  hysterectomy.  We 
have  already  referred  to  the  additional  danger  of  infection 
of  the  ligatures  in  total  hysterectomy.  This,  with  the  risk 
of  the  aforementioned  injuries,  results  in  an  increased 
mortality  and  morbidity  rate  in  total  hysterectomy  as 
compared  with  that  of  the  subtotal  method. 

These  remarks  on  the  relative  difficulties  of  the  two 
operations,  founded  upon  experience  of  the  work  of  expert 
operators,  obviously  apply  with  much  greater  force  to  the 
practice  of  those  inexperienced  in  gynaecological  surgery. 

Setting,  then,  the  advantages  claimed  for  the  habitual 
practice  of  total  hysterectomy  against  its  disadvantages,  we 
are  of  opinion  that  it  is  not  the  operation  of  election  in  all 


222  GYNECOLOGICAL  SURGERY 

cases,  and  that  the  cervix  should  be  conserved  wherever 
it  may  reasonably  be  held  to  be  healthy. 

III.    COMPARATIVE  ADVANTAGES  OF  ABDOMINAL 
AND   VAGINAL   HYSTERECTOMY 

The  frequency  with  which  vaginal  hysterectomy  is  per- 
formed varies  very  considerably  in  different  countries 
and  in  the  practice  of  different  surgeons.  There  are  some 
who  consider  this  method  to  be  the  one  of  election  when 
the  extirpation  of  the  uterus  is  indicated  and  it  is  possible 
to  remove  it  by  this  route..  There  are  others  who  only 
resort  to  the  method  occasionally,  and  then  because  there 
is  some  very  strong  contra-indication  to  the  abdominal 
operation. 

There  are  many  cases  in  which  -the  performance  of 
vaginal  hysterectomy  is  obviously  out  of  the  question  on 
account  of  the  size,  fixity,  or  uncertain  nature  of  the  tumour. 
But,  limiting  the  discussion  to  those  cases  in  which  the 
uterus  is  removable  by  either  route,  the  advantages  and 
disadvantages  of  vaginal  and  abdominal  hysterectomy  can 
be  discussed  under  the  following  heads  : — 

i.  Shock. — There  can  be  no  doubt  that  when  vaginal 
hysterectomy  is  performed  in  suitable  cases,  post-operative 
shock  is  much  less  than  if  the  uterus  had  been  removed 
per  abdomen.  This  is  possibly  due  to  the  lesser  disturbance 
and  exposure  of  the  intestines  and  to  the  position  of  the 
peritoneal  wound,  for  it  is  certain  that  the  pelvic  peri- 
toneum differs  markedly  from  that  lining  the  remainder 
of  the  abdominal  cavity  in  its  resistance  to  shock  and  the 
spread  of  infection.  From  this  point  of  view,  therefore, 
the  operation,  other  things  being  equal,  is  peculiarly  suit- 
able for  those  patients  who  are  unable  to  withstand  any 
prolonged  shock. 

2.  Drainage. — In  cases  where  drainage  is  indicated 
after  hysterectomy,  it  is  claimed  that  it  will  be  more 
efficiently  carried  out  per  vaginam  than  through  an  abdo- 
minal  incision.       The   relative   merits    of    abdominal    and 


HYSTERECTOMY  223 

vaginal  drainage  have  been  already  discussed  (p.  47). 
Quite  apart  from  the  question  of  the  facility  with  which 
discharges  may  escape  from  a  vaginal  or  an  abdominal 
wound,  the  danger  of  infecting  a  non-septic  area  of  the 
peritoneum  when  abdominal  drainage  is  employed  has  to 
be  considered,  and  therefore,  when  it  is  deemed  necessary 
to  remove  the  uterus  for  acute  septic  infection,  it  is,  from 
this  point  of  view,  safer  to  adopt  the  vaginal  route. 

3.  Operative  accessibility. — In  certain  cases,  as,  for 
instance,  when  the  patient  is  very  fat,  the  uterus  is  more 
accessible  by  the  vagina  than  by  the  abdomen,  and  more 
especially  if  the  uterus  is  at  the  same  time  not  enlarged, 
or  even  smaller  than  normal. 

Occasions  may  arise  also  when  an  abdominal  wound  is 
contra-indicated  by  reason  of  some  unhealthy  condition 
of  the  abdomen,  such  as  eczema,  septic  blisters  from  too 
hot  fomentations,  suppurative  omphalitis  or  the  presence 
of  a  colotomy  wound,  and  also  where,  in  great  emergency, 
the  abdominal  wall  is  in  a  filthy  condition.  In  these  cir- 
cumstances, if  the  case  is  otherwise  suitable,  vaginal 
hysterectomy  is  indicated. 

In  the  majority  of  cases,  however,  it  cannot  be  doubted 
that  the  operation  is  much  easier  through  an  abdominal 
wound. 

This  advantage  of  greater  operative  ease  would  not 
in  itself  weigh  down  the  considerations  that  tell  in 
favour  of  vaginal  hysterectomy,  but  the  increased  facility 
accorded  to  the  operator  is  associated  with  greater  safety 
to  the  patient,  since  the  relation  of  the  diseased  organ  to 
the  adjacent  structures  can  be  more  clearly  defined,  and 
any  complication,  such  as  adherent  intestine,  omentum,  or 
appendix,  can  be  more  easily  dealt  with  and  runs  no  risk 
of  being  overlooked.  Again,  the  separation  of  adhesions 
is  more  easily  and  safely  accomplished  by  abdominal 
manipulation  ;  any  bleeding-points  can  be  more  certainly 
secured  ;  and  the  bladder,  rectum,  and  ureters  run  less 
risk  of  being  wounded. 


224  GYNAECOLOGICAL  SURGERY 

In  abdominal  hysterectomy  the  cut  surfaces  of  the 
broad  ligaments  and  vagina  are  separated  from  the  abdo- 
minal cavity  by  the  accurately  sutured  peritoneal  flaps, 
whereas  in  vaginal  hysterectomy  these  raw  surfaces  are 
imperfectly  covered,  and  therefore  form  possible  sites  for 
intestinal  adhesions.  By  the  abdominal  route  the  operator 
is  at  liberty  to  conserve  the  cervix  if  he  wishes  to  do  so, 
or  even  the  whole  uterus  if  he  finds  the  tumour  enucleable, 
whereas  by  the  vagina  he  has  no  such  choice.  Finally,  in 
cases  where  the  uterus  is  enlarged  or  adherent,  its  removal 
by  the  abdomen  can  be  carried  out  so  much  more  quickly 
that  this  more  than  counterbalances  the  lessened  tendency 
to  shock  and  the  quicker  convalescence  associated  with  the 
vaginal  operation. 

4.  Site  of  wound. — One  of  the  chief  drawbacks  to  ab- 
dominal hysterectomy  is  the  parietal  wound,  which,  apart 
from  its  unsightly  appearance,  is  liable  to  stitch-abscess 
or  to  a  hernia.  A  vaginal  wound,  on  the  other  hand, 
leaves  no  visible  scar,  and,  though  it  suppurates  more 
frequently,  does  not  cause  so  much  distress  as  an  ab- 
dominal sinus,  whilst  a  hernia  in  this  situation  is  unknown. 
On  the  other  hand,  a  vaginal  scar  may  be  the  cause  of 
dyspareunia. 

After  a  careful  consideration  of  the  arguments  advanced 
on  both  sides,  and  whilst  admitting  that  the  results  of 
those  who  operate  by  the  vaginal  route  as  a  routine  method 
are  in  many  cases  very  good,  we  are  still  of  opinion  that 
abdominal  hysterectomy  in  the  majority  of  cases  is  the 
safer  procedure  for  the  patient. 

The  scope  of  vaginal  hysterectomy  has  of  late  years 
been  extended  by  the  adoption  of  Schauta's  paravaginal 
incision,  presently  to  be  described,  which  very  considerably 
enlarges  the  operator's  field  of  action.  While,  however, 
the  difficulty  of  access  to  the  pelvis  is  by  these  means 
diminished  and  larger  tumours  can  be  dealt  with,  many 
of  the  disadvantages  already  discussed  are  not  materially 
obviated. 


CONSERVATION  OF  OVARIES  225 

IV.   THE   CONSERVATION   OF   OVARIES 

To  remove  a  healthy  functional  ovary  in  order  to 
facilitate  an  operation  is;  as  a  rule,  bad  practice. 

The  effect  of  removal  of  both  ovaries  in  a  woman 
varies  considerably  according  to  her  age  and  temperament. 
The  observations  of  Crewdson  Thomas  show  that  by  the 
time  a  woman  has  reached  the  age  of  40  the  value  of 
the  ovaries  has  depreciated,  whilst  when  she  is  under  40 
their  absence  may  either  produce  no  changes  worth  speak- 
ing about  or  may  be  responsible  for  violent  menopausal 
symptoms. 

The  effect  of  ablation  of  the  ovaries  on  sexual  desire 
varies.  As  a  rule,  this  is  lessened,  accompanied  as  it  some- 
times is  by  dyspareunia  from  atrophy  of  the  vagina  and 
postoperative  kraurosis.  The  result  is  at  times  the  reverse 
of  this,  and  in  some  cases  the  orgasm  is  enhanced  by  the 
fact  that  painful  ovaries  which  before  interfered  with  its 
consummation  are  no  longer  present. 

The  result  of  oophorectomy  on  the  mind  varies  con- 
siderably, according  to  the  individual.  That  the  removal 
of  ovaries  per  se  is  a  cause  of  insanity  or  mental  instability 
we  do  not  believe.  This  used  to  be  a  terror  held  out  to 
women  on  whom  some  operation  on  the  genital  organs 
was  contemplated,  but  experience  has  shown  that  such 
teaching  has  no  foundation  on  fact.  On  the  other  hand, 
it  is  quite  certain  that  where  mental  stability  is  trembling 
in  the  balance,  the  removal  of  the  ovaries,  by  adding  the 
nervous  symptoms  of  the  menopause,  may  precipitate  the 
catastrophe.  In  such  patients  any  operation  is  to  be 
avoided  if  possible,  and,  for  the  reason  given  above,  removal 
of  the  ovaries  especially. 

It  must  also  be  remembered  that  whilst  it  is  best  to 
conserve  both  ovaries  if  feasible,  even  part  of  one  may 
be  of  service  to  its  owner. 

Under   certain   conditions,    apparently   healthy   ovaries 
may  have  to  be  removed,  as,  for  example,  when  their  raw 
p 


226  GYNAECOLOGICAL  SURGERY 

surface  due  to  the  separation  from  surrounding  structures 
is  bleeding  too  freely  to  be  satisfactorily  controlled  by 
ligatures,  or  when,  during  the  removal  of  a  broad-ligament 
cyst,  the  ovary  is  found  so  flattened  out  that  its  separa- 
tion and  conservation  would  add  a  considerable  risk  to 
the  operation.  If,  again,  the  surgeon  suspects  malignant 
disease  in  the  uterus,  he  should  remove  the  ovaries,  because 
by  so  doing  he  widens  the  area  of  excision. 

In  an  operation  on  a  patient  over  50  years  of  age, 
the  ovaries  may  be  removed  without  hesitation  if  the 
proceeding  is  facilitated  thereby. 

A  number  of  experiments  by  different  observers  have 
shown  that  in  animals  the  removal  of  the  uterus  does 
not  hinder  ovulation,  and  apparently  this  is  also  true  of 
women.  In  our  experience,  a  hysterectomy  with  con- 
servation of  the  ovaries  in  a  woman  below  40  years  of 
age  does  not  greatly  accelerate  the  appearance  of  meno- 
pausal symptoms.  This  subject  is  further  discussed  in 
Chapter  xli. 


CHAPTER    XI 
VAGINAL    HYSTERECTOMY 

I.     THE    LIGATURE    METHOD 

Preparation  of  the  patient. — See  pp.  82-84. 

Instruments. — The  instruments  given  in  the  general  list 
on  p.  276  will  be  needed,  but  all  the  pressure-forceps 
must  be  of  the  long  variety,  and  in  addition  a  douche 
apparatus,  a  Clover's  crutch,  an  Auvard's  speculum,  two 
vaginal  retractors,  an  additional  volsella,  and  a  Worrall's 
blunt-pointed  needle  will  be  required. 

Cleansing  the  vaginal  canal. — The  vagina  is  thoroughly 
scrubbed  with  soap  and  water  by  means  of  swabs  attached 
to  long  forceps,  after  which  it  is  well  douched  with  biniodide 
of  mercury,  1 — 2,000.  If  the  operation  is  being  performed 
for  carcinoma  of  the  cervix,  the  growth  should  first  be 
thoroughly  curetted  and  cauterized,  or  if  it  is  small  it 
may  be  entirely  excised.  In  all  cases  it  is  well  to  close 
the  cervical  canal  with  a  No.  6  silk  ligature,  the  long  ends 
of  which  can  be  used  as  a  tractor. 

Operation. — The  following  are  the  steps  of  the  opera- 
tion : — 

i.  Identifying  the  limits  of  the  bladder. — Auvard's 
speculum  having  been  inserted  into  the  vagina,  a  sound  is 
passed  into  the  bladder  and  the  relations  of  this  organ  are 
carefully  noted.  Especially  is  it  important  to  determine 
how  far  down  the  bladder  reaches  on  the  anterior  wall  of 
the  cervix,  since,  on  stripping  it  off  the  cervix  prior  to 
opening  the  utero-vesical  pouch,  the  bladder  may  be  injured. 

ii.  Separating  the  bladder. — By  traction  on  the  cervix 
the  uterus  is  pulled  down  towards  the  vaginal  outlet.  With 
a  scalpel  the  mucous  membrane  on  the  front  half  of  the 

227 


228 


GYNECOLOGICAL  SURGERY 


cervix  is  incised  transversely  as  high  up  as  the  previously 
ascertained  position  of  the  bladder  allows  (Fig.  122).  The 
bladder  is  then  separated  from  the  cervix,  at  first  with 
the  handle  of  the  scalpel  or  with  scissors  (Fig.  123),  and 
later  on,  as  the  layer  of  cellular  tissue  between  the  bladder 


Fig.  122. — Vaginal  hysterectomy 
by  the  ligature  method  :  An- 
terior incision  of  the  cervix. 


and  the  cervix  becomes  looser,  with  the  forefinger,  until 
the  utero-vesical  reflection  of  peritoneum  is  reached 
(Fig.  124). 

iii.  Opening  the  utero-vesical  pouch. — This  is  effected 
by  pushing  the  left  index-finger  up  to  the  peritoneal  reflec- 
tion and  then  passing  along  it  with  the  right  hand  a  pair  of 
blunt-pointed  scissors  till  their  ends  touch  the  peritoneum, 
when  one  or  two  very  gentle  snips  are  generally  sufficient 
to   cut   through    the   peritoneum.      The    left   forefinger   of 


VAGINAL  HYSTERECTOMY 


231 


each  hand  can  then  be  pushed  through  into  the  utero- 
vesical  pouch  and  the  opening  enlarged  laterally  by  a 
stretching  movement  (Figs.  125  and  126). 


Fig.   127. — Incising  the  cervix  posteriorly. 


iv.  Opening  the  utero-rectal  pouch. — The  cervix  is 
next  drawn  forwards  and  the  mucous  membrane  on  its 
posterior  surface  is  incised  at  the  level  of  the  posterior 
vaginal  fornix  (Fig.  127).  The  mucous  membrane  is  now 
reflected  with  the  handle  of  the  scalpel   (Fig.   128),  until 


232 


GYNAECOLOGICAL  SURGERY 


the  peritoneum  is  reached,  which  membrane  is  cut  through 
with  the  points  of  the  scissors  pressed  against  the  uterus 
(Fig.  129).     The  opening  is  then  enlarged  with  the  fingers 


Fig.   128. — Pushing  back  the  mucous  membrane. 

(Fig.  130).  A  quicker  and  just  as  efficient  a  method  of 
opening  the  utero-rectal  pouch  is  to  cut  right  into  it  with 
the  points  of  the  scissors  directed  towards  the  uterus,  just 
where  the  posterior  vaginal  wall  is  reflected  on  to  the  cervix. 
In  either  case  the  primary  cut  is  then  lengthened    trans- 


VAGINAL  HYSTERECTOMY  233 

versely  and  the  incision  is  carried  round  on  each  side  of 
the  cervix  till  the  anterior  and  posterior  incisions  are 
continuous. 


Fig.   129. — Opening  the  utero-rectal  pouch. 

v.  Insertion  of  swab. — After  Douglas's  pouch  has  been 
opened,  a  swab  to  which  has  been  attached  a  piece  of  tape 
is  passed  into  it  through  the  opening  made  behind  the 
cervix.     This  prevents  the  small  intestine  from  prolapsing. 

vi.  Ligaturing     and     cutting     the     broad     ligaments. — 


234  GYNECOLOGICAL  SURGERY 

An  assistant  having  pulled  the  uterus  downwards  and  to 
one  or  the  other  side,  so  as  to  give  as  much  room  as  possible 
in  the  lateral  fornix,  the  operator  inserts  the   index-finger 


Fig.  130. — Enlarging  the  opening  in  the  utero-rectal 
pouch. 

of  his  left  Jiand  into  the  utero-rectal  pouch,  palmar  surface 
forwards,  and  by  its  pressure  steadies  that  portion  of 
the  broad  ligament  which  is  in  relation  with  the  side  of  the 


VAGINAL  HYSTERECTOMY 


235 


cervix,  and  at  the  same  time  with  the  aid  of  the  thumb 
he  identifies  the  uterine  artery  (Fig.  131).  He  now,  with 
a  Worrall's  needle  held  in  the  right  hand,  transfixes 
the  broad  ligament  from  before  backwards  and  well  above 
the  uterine  artery  and  as  near  to  the  cervix  as  possible 
(Fig.  132).     The  needle  is  tilted  somewhat  so  that  its  end 


Fig.   131. — Identifying  the  uterine  artery. 

impinges  on  the  left  finger,  and  a  ligature  of  No.  4  silk 
having  been  attached  to  the  needle,  the  latter  is  withdrawn 
and  disengaged  from  the  silk.  The  ligature  is  then  firmly 
tied  (Fig.  133),  and  the  ends  are  left  hanging  out  of  the 
vagina  and  secured  by  pressure-forceps.  By  this  ligature 
the  uterine  artery  should  be  secured,  and  the  tissue  between 
the  ligature  and  the  uterus  is  then  divided  with  scissors 


236 


GYNECOLOGICAL  SURGERY 


(Fig.  134).  The  artery  on  the  opposite  side  having  been 
secured  by  a  similar  method,  the  uterus  can  be  drawn 
much  lower  into  the  vagina.  By  similar  procedures  the 
rest  of  the  broad  ligament  on  each  side  is  transfixed, 
ligatured,  and  divided  close  to  the  uterus.  The  highest 
ligature  to  be   passed    (Fig.   135)   should  be  used  double, 


Fig.  132. — Transfixing  the  lower  part  of  the 
broad  ligament. 

and,  having  been  divided,  one  half  is  used  for  ligatur- 
ing the  Fallopian  tube  and  the  ovarian  vessels,  and  the 
other  for  the  round  ligament  of  the  uterus  (Fig.  136), 
which  structures,  unless  they  are  firmly  secured,  may  re- 
tract, causing  the  ligature  to  slip,  and  giving  rise  to  trouble- 
some bleeding  which  may  be  somewhat  difficult  to  control. 


VAGINAL  HYSTERECTOMY 


237 


When  the  upper  part  of  the  broad  ligament  on  each  side 
has  been  divided,  the  uterus  is  freed  (Fig.  137)  and  can  be 
removed,  and  if  the  vessels  have  been  properly  secured, 
there  is  no  oozing  from  the  stumps.  If  any  oozing  is  present, 
the  bleeding-point  is  secured  with  pressure-forceps  and  liga- 
tured with  No.  4  silk.     If  the  open  mouth  of  the  cut  end  of 


Fig.   133. — Ligaturing  the  lower  part  of  the 
broad  ligament. 


the  uterine  artery  can  be  seen,  it  should  be  picked  up  with 
pressure-forceps  and  ligatured  separately  with  No.  4  silk. 
Exactly  how  many  ligatures  will  have  to  be  applied  on 
each  side  will  vary  with  the  skill  of  the  operator  and  the 
size  of  the  uterus ;  usually  two  single  and  one  double  on 
each  side  suffice,  but  the  cut  edge  of   the  broad  ligament 


238 


GYNECOLOGICAL  SURGERY 


must  be  rendered  quite  bloodless,  and  if  there  is  any  oozing 
the  part  where  it  occurs  must  be  re-tied. 

The  vagina  is  now  thoroughly  swabbed,  not   douched, 
with  a  warm   solution    of   biniodide    of  mercury,  I — 2,000, 


Fig.   134. — Division  of  the  lower  part  of  the 
broad  ligament. 

and  the  swab  in  the  utero-rectal  pouch  is  then  removed. 
The  ends  of  the  ligatures  may  be  treated  in  one  of  two 
ways  :  some  operators  cut  the  ends  off  short,  while  others 
leave  them  long.  There  is  a  certain  advantage  in  leaving 
the   ends   long,  inasmuch   as,  if  any  bleeding  takes   place 


VAGINAL  HYSTERECTOMY 


239 


after  the  operation,  by  pulling  on  them  the  cut  surfaces 
of  the  broad  ligament  can  be  brought  down,  and  the  oozing- 
point  quickly  seen  and  dealt  with  (Fig.  138).  Further, 
after  the  end  of  a  week  the  separation  of  the  ligatures  may 
be  hastened  by  daily  making  gentle  traction  on  the  long 


Fig.  135. — Transfixing  the  upper  part  of  the 
broad  ligament. 

ends.  The  method  has,  however,  the  disadvantage  of 
increasing  the  liability  to  suppuration,  so  that  we  prefer 
to  cut  them  short  and  leave  the  case  in  the  same  con- 
dition as  obtains  after  an  abdominal  total  hysterectomy. 
They  should  not,  however,  be   cut  until  the  operation  is 


240 


GYNECOLOGICAL   SURGERY 


concluded  and  it  is  certain  that  all  the  vessels  are  properly 
secured. 

vii.  Treatment    of   the   vaginal   vault. — The   treatment 


Fig.   136. — Ligaturing  the  upper  part  of  the 
broad  ligament. 

of  the  vaginal  vault  varies  with  different  operators.  The 
most  satisfactory  proceeding  is,  probably,  to  let  the  cut 
edges  of  the  vagina  fall  together  naturally,  promoting 
drainage  by  passing  into  the  utero-rectal  pouch  a  piece  of 


VAGINAL  HYSTERECTOMY 


241 


the  gauze  with  which  the  vagina    is    lightly  packed,   and 
keeping  it  there  for  twenty-four  hours. 

Others  prefer  carefully  to  suture  the  cut  edges  of  the 
peritoneum  over  the  vagina  with  a  continuous  suture  of 


Fig.   137. — Dividing  the  upper  part  of  the 
broad  ligament. 

No.  2  silk,  whilst  others  again  pass  a  single  suture  at  the 
external  angles  of  the  vaginal  incision  so  as  to  narrow 
but  not  occlude  its  open  upper  end  (Fig.  139). 

Difficulties,     i.    Separating   the    bladder. — Sometimes  a 
good  deal  of    trouble    is    experienced    in    separating   the 
Q 


242 


GYNECOLOGICAL  SURGERY 


bladder.     This  may  be   due   either  to   the   fact   that  the 
operator  when  using  the  scissors  cuts  into  the  muscle  of 
the  cervix  instead  of  through  the  loose  connective  tissue, 
or  to  the  connective  tissue  being  denser  than  normal. 
In  the  first  event,  if  the  operator  fails  to  recognize  what 


Fig.  138. — Inspecting  the  pedicles. 

he  is  doing,  he  may  open  the  cervical  canal,  especially  if 
the  cervix  has  been  rendered  soft  by  growth. 

If  dense  connective  tissue  is  preventing  the  proper 
separation  of  the  bladder,  it  must  be  divided  by  series 
of  small  cuts,  made  with  the  scissors  held  on  the  flat,  till 
looser  connective  tissue  is  reached.  In  such  cases  it  is 
useful  to  push  the  forefinger  of  the  right  hand  well  out 
on  each  side  of  the   cervix  towards  the  broad  ligament, 


VAGINAL  HYSTERECTOMY 


243 


as  in  this  region  the  vesical  walls  are  more  loosely  attached. 
From  the  sides  it  will  then  be  possible  to  work  inwards 
towards  the  anterior  surface  of  the  cervix  and  strike  the 
proper  plane  of  cleavage. 

ii.  Opening  the  utero-vesical  pouch.— Another  difficulty 


Fig.  139.— Treatment  of 
the  vaginal  vault. 


may  present  itself  on  an  attempt  being  made  to  open  the 
utero-vesical  pouch. 

The  reason  is  twofold.  Either  the  operator,  if  inex- 
perienced, is  uncertain  when  his  finger  has  reached  the 
peritoneum,  and  is  somewhat  timid  in  using  the  scissors  ; 
or,  what  is  more  probable,  the  forefinger  of  the  left  hand 
pushes  the  peritoneum  in  front  of  it  so  that  it  is  continually 
"  running  away  from  him." 

A  useful  method  of  identifying  the  peritoneal  reflection 


244  GYNECOLOGICAL  SURGERY 

is  to  rub  what  you  take  to  be  it  against  the  anterior  surface 
of  the  uterus,  when  if  the  tissue  is  the  peritoneum  it  will 
slip  about  on  the  uterus  with  an  oily  sort  of  feeling. 

If,  on  the  other  hand,  the  operator  experiences  difficulty 
in  steadying  the  peritoneum  during  its  incision,  a  pair 
of  long  forceps  can  be  passed  up  guided  by  the  forefinger 
till  the  peritoneum  is  reached,  when  this  membrane  can 
be  clamped  and  then  pulled  down  and  dealt  with.  An 
additional  help  may  be  gained  by  means  of  a  long  anterior 
speculum  pushed  up  between  the  bladder  and  the  cervix 
(Fig.  125).  Lastly,  the  opening  of  the  utero-vesical  pouch 
can  be  postponed  until  Douglas's  pouch  has  been  opened, 
when  the  index  and  middle  fingers  of  the  left  hand  can  be 
passed  into  it  up  along  the  posterior  surface  of  the  uterus 
over  the  edge  of  the  broad  ligament,  and  so  to  the  utero- 
vesical  reflection,  when  the  peritoneum  can  be  incised  as 
it  rests  against  the  fingers. 

iii.  Opening  the  utero-rectal  pouch. — If  the  posterior 
incision  is  made  with  a  scalpel,  and  the  mucous  membrane 
then  separated  with  its  handle  or  the  forefinger,  the  cellular 
tissue  between  the  vagina  and  rectum  may  be  opened 
up  and  the  vagina  separated  from  the  rectum  for  some 
distance  before  the  mistake  is  discovered. 

iv.  Bleeding  from  the  posterior  flap. — The  posterior 
cut  edge  of  the  vagina  and  peritoneum  is  much  more 
fleshy  than  the  anterior,  and  the  oozing  of  blood  that 
takes  place  from  its  surface  may  be  very  troublesome  both 
during  the  removal  of  the  uterus  and  afterwards.  The 
same  difficulty  may  present  itself  with  the  anterior  flap, 
though  in  a  much  lesser  degree. 

This  oozing,  especially  if  it  comes  only  from  one  or 
two  points,  can  be  temporarily  stopped  by  pressure-forceps. 
A  better  way  to  check  the  oozing,  if  it  is  at  all  trouble- 
some, is  to  obliterate  the  raw  surface  of  the  flap  by  suturing 
the  peritoneum  to  the  mucous  membrane  with  a  continuous 
suture  of  No.  2  silk. 

v.  Narrow    vagina. — If    the    vagina    is    narrow,    as     in 


VAGINAL  HYSTERECTOMY 


245 


virgins  or  women  who  have  not  borne  children,  the  opera- 
tion becomes  much  more  difficult,  and  the  operator,  unless 
he  be  very  expert,  may  rind  great  difficulty  in  passing  and 
tying  the  ligatures  for  want  of  sufficient  room.  In  these 
cases  it  is  a  great  help  to  perform  a  paravaginal  section. 


Fig.  140. — -Incision  in  paravaginal  section. 


This  is  effected  by  incising  the  vagina  along  the  junction 
of  the  posterior  and  left  lateral  wall  from  the  vault 
downwards,  and  then  carrying  the  incision  backwards 
through  the  skin  around  the  rectum  towards  the  coccyx, 
the   anterior  fibres  of  the  left  levator   ani   being  divided 


246 


GYNECOLOGICAL  SURGERY 


(Figs.  140  and  141).  A  good  deal  of  bleeding  ensues,  which 
must  be  checked  by  ligatures  and  the  pressure  of  the  pos- 
terior speculum.  At  the  conclusion  of  the  operation  the 
wound  is  sutured 

vi.  Application  of  ligatures. — If  any  difficulty  is  found 
in  passing  the  ligatures  by  the  method  described  at  p.  235, 
this  can  sometimes  be  overcome  by  inserting  the  needle 
into  the  utero-rectal  pouch  and  transfixing  the  broad 
ligament  from  behind  forwards. 


Fig.   141. — Retraction  of  the  wound  of  the  paravaginal 
section. 


vii.  Passing  the  higher  ligatures. — After  division  of  the 
base  of  the  broad  ligaments,  it  may  be  found  that  the  uterus 
cannot  be  pulled  down  properly,  and  in  that  case  much 
difficulty  may  be  experienced  in  passing  the  higher  liga- 
tures. This  difficulty  will  be  due  either  to  infiltration  of 
the  surrounding  connective  tissue  by  cancer  or  inflammatory 
products,  in  which  case  it  may  be  impossible  to  finish  the 
operation  from  the  vagina  ;  or  to  the  presence  of  adhesions, 
or  to  the  large  size  of  the  uterus. 


VAGINAL  HYSTERECTOMY 


247 


Infiltration  of  the  broad  ligaments  should  have  been 
discovered  before  the  operation  was  started,  by  pulling 
the  cervix  with  the  volsella  down  to  the  vulva  and  examin- 
ing the  broad  ligaments  and  the  utero-sacral  ligaments 
per  rectum.     If  the  cervix  cannot  be  drawn  down  to  the 


Fig.  142.— Anteflexing 
the  uterus — first  step. 


vulva,  this  in  itself  is  an  indication  that  the  operation  on 
the  ordinary  lines  will  be  a  failure,  and  the  more  extensive 
procedures  as  practised  by  Schauta  will  have  to  be  followed, 
or  the  uterus  removed  by  the  abdominal  route. 

Supposing  the  fixation  is  due  to  adhesions,  they  should 


248  GYNAECOLOGICAL  SURGERY 

be  gently  broken  down,  and  if  the  Fallopian  tubes  or 
ovaries  are  diseased  these  should  be  removed  by  placing 
the  upper  ligature  outside  them,  i.e.  round  the  ovarico- 
pelvic  ligaments.  If  the  difficulty  is  due  to  the  size  of 
the  uterus,  this  can  be  surmounted  in  one  of  two  ways : 


Fig.  143. — Anteflexing  the  uterus — second  step. 

either  the  fundus  of  the  uterus  can  be  seized  with  a  volsella 
and,  the  uterus  being  ante  verted,  delivered  through  the 
utero-vesical  incision  (Figs.  142  and  143),  when  the  top 
portions  of  the  broad  ligaments  come  into  view ;  or  the 
uterus  can  be  bisected  with  a  stout  pair  of  scissors  and 
each  half  removed  separately  (Figs.  144  and  145). 

Dangers,     i.  Wounding  the  bladder. — This   is,  perhaps, 


VAGINAL  HYSTERECTOMY 


249 


the  commonest  accident  associated  with  vaginal  hysterec- 
tomy. Although  at  times  its  avoidance  would  appear 
to  be  well-nigh  impossible,  since  it  now  and  again  happens 
to  the  most  expert  operators,  nevertheless  the  liability  to 
this  accident  can  be  almost  reduced  to  a  vanishing  point 


Fig.   144. — Bisecting  the  uterus — first  step. 

if  during  the  separation  of  the  bladder  the  operator  keeps 
careful  note  of  its  position  with  the  bladder-sound.  As  there 
is  much  greater  danger  of  this  organ  being  wounded  sup- 
posing it  contains  urine,  the  operator  should  pass  a  catheter 
himself  before  making  the  first  incision,  for,  although  the 
nurse  may  have  emptied  the  bladder  before  the  operation, 


250 


GYNAECOLOGICAL  SURGERY 


it   is   a  well-known   fact   to  most  medical  men  from   the 
days  of  their  earliest  professional  examinations  how  rapidly 


Fig.  145. — Bisecting  the  uterus — second  step. 

the  kidney  secretes  under  the  influence  of  fright  or  anxiety. 
If  the  bladder  is  opened,  it  must  be  sutured  by  the  method 
described  at  p.  539. 

ii.  Wounding    the    bowel.— If,   when  making  the   first 


VAGINAL  HYSTERECTOMY  251 

cut  with  the  scissors,  the  points  are  directed  against  the 
vaginal  wall  instead  of  the  uterus,  the  rectum  may  be 
wounded,  and  it  may  also  be  wounded  if  the  cellular  tissue 
between  the  vagina  and  the  rectum  is  opened  up. 

The  small  intestines  or  omentum,  if  they  lie  low  in  the 
utero-rectal  pouch,  may  be  wounded  if  care  is  not  taken 
when  cutting  into  it.  If  the  bowel  is  wounded,  it  must 
be  at  once  sutured  according  to  the  method  described 
on  page  545.  A  faecal  fistula  may  result,  which,  however, 
as  a  rule,  eventually  closes. 

iii.  Oozing. — At  times,  although  there  is  no  serious 
bleeding,  some  oozing  may  take  place  from  one  or  other 
of  the  cut  surfaces,  in  which  case  it  may  be  found  that 
this  will  be  better  controlled  by  clamping  the  oozing  surface 
with  a  pair  of  long  pressure  or  ring  forceps,  instead  of 
ligaturing  it.  The  forceps  should  be  removed  in  thirty-six 
hours. 

iv.  Injury  to  ureters. — As  the  ureter  is  less  than  an 
inch  from  the  cervix  at  the  point  where  the  uterine  artery 
is  ligatured,  there  is  a  risk  of  its  inclusion,  or  it  may  be 
cut  during  the  division  of  the  lower  part  of  the  broad 
ligament ;  hence  the  importance  of  keeping  as  close  to  the 
uterus  as  possible  when  passing  the  lower  ligatures  and 
cutting  the  supravaginal  cervix  free  (p.  236). 

This  accident  unfortunately  is  not  so  very  uncommon. 
If  both  ureters  are  occluded  the  patient  will  die  of  anuria 
unless  the  obstruction  is  removed.  If  they  are  injured  a 
ureteral  fistula  is  the  result.  Nothing  may  be  noticed  for 
some  days  if  the  ureter  has  been  tied  as  well,  but  when 
the  ligature  separates,  urine  commences  to  dribble  from  the 
vagina. 

This  complication  may  be  mistaken  for  a  vesical  fistula, 
but  with  the  latter  all  the  urine  dribbles  away,  whereas  if 
the  escape  of  urine  is  due  to  a  ureteral  fistula  the  urine 
on  the  sound  side  will  collect  in  the  bladder.  If  there  is 
any  doubt,  a  solution  of  boric  acid,  coloured  with  methylene 
blue,   can  be  injected  into  the  bladder,   and  its  presence 


252  GYNAECOLOGICAL  SURGERY 

ascertained  by  placing  a  wool  swab  in  the  vagina.  As  one 
of  the  methods  of  treatment  for  a  ureteral  fistula  is  to 
remove  the  kidney  of  the  corresponding  side,  it  will  be 
seen  how  important  it  is  to  determine  for  certain  which 
ureter  has  been  injured.  We  know  of  a  case  where  the 
failure  to  take  this  precaution  resulted  in  the  wrong 
kidney  being  removed. 

v.  Bleeding. — There  is  always  a  certain  amount  of 
oozing  after  the  operation,  but  if  the  bleeding  is  at  all 
free  either  a  ligature  has  slipped  or  some  vessel  which  did 
not  bleed  during  the  operation  has  started  doing  so.  In 
either  case  the  bleeding  spot  must  be  religatured. 

vi.  Implantation  of  cancer-cells. — Care  must  be  taken 
when  removing  the  uterus  for  carcinoma  to  avoid  implan- 
tation of  the  malignant  cells.  In  the  case  of  a  cervical 
growth  this  should  be  thoroughly  destroyed  beforehand 
with  the  cautery. 

If  carcinoma  of  the  body  is  present,  great  care  should 
be  taken  entirely  to  suture  up  the  external  os  before 
commencing  the  operation.  In  any  case  of  malignant 
disease  it  is  most  important  not  to  cut  into  the  uterine 
wall  whilst  removing  it.  Some  of  these  cases  present  a 
condition  of  pyometra,  and  it  is  important  to  pass  a 
sound  into  the  cavity  to  evacuate  any  pus  that  may 
be  there  before  starting  to  remove  the  organ. 

Removal  of  the  appendages. — In  all  cases  in  which 
the  operation  is  performed  for  carcinoma  of  the  uterus,  the 
Fallopian  tubes  and  ovaries  should  be  removed,  as  also 
in  septic  cases  and  in  all  other  conditions  where  they 
are  obviously  diseased;  otherwise  they  should  be  spared, 
since  their  removal  increases  the  difficulty  of  the  operation 
owing  to  the  inaccessibility  in  some  cases  of  the  ovarico- 
pelvic  ligament.  It  is  occasionally  good  practice  to  post- 
pone their  removal  until  the  uterus  has  been  cut  away. 

After-treatment. — See  p.  45  and  Chapter  xxxn.  The 
gauze  packing  is  removed  from  the  vagina  in  forty-eight 
hours.     After  this,  for  the  first  week  the  vagina  should  be 


VAGINAL  HYSTERECTOMY 


253 


wiped  out  twice  daily  with  swabs  held  in  ring  forceps 
and  soaked  in  1 — 5,000  biniodide  of  mercury.  At  the  end 
of  that  time,  vaginal  douches  of  the  same  solution  should 
be  given  at  low  pressure  until  all  discharge  has  ceased. 

The  patient  gets  up,  if  she  has  progressed  normally,  in 
three  weeks. 


Fig.   146. — Vaginal  hysterectomy  by  the  clamp  ligature 
method  :   Clamping  the  uterine  artery. 


II.    BY   CLAMP   AND   LIGATURE 

Instead  of  ligaturing  the  vessels  before  removing  the 
uterus,  an  alternative  method  is  temporarily  to  clamp  the 
broad  ligaments,  postponing  the  ligation  till  the  uterus 
has  been  removed.  This  procedure  has  the  advantages 
that  it  is  quicker,  and  that  the  ligatures  on  the  broad 
ligaments  can  be  more  securely  tied.      Indeed,  when  the 


254 


GYNAECOLOGICAL  SURGERY 


vagina  is  narrow  and  the  uterus  is  high  up,  it  may  be 
most  difficult  or  even  impossible  to  apply  the  ligatures 
before  the  uterus  is  removed.  On  the  other  hand,  it  cannot 
be  gainsaid  that  ligation  of  the  broad  ligaments  after  the 
uterus  is  removed  is  more  difficult,  and  that  in  the  event 


Fig.  147. — Dividing  the  base  of  the  broad  ligament. 

of  the  forceps  or  ligature  slipping  off,   the  bleeding-point 
is  more  difficult  to  secure. 

Operation. — Up  to  the  point  when  the  broad  ligaments 
are  about  to  be  ligatured,  the  operation  proceeds  on  the 
same  lines  as  those  described  in  the  first  section  of  this 
chapter  (Figs.  122-130). 


256 


GYNECOLOGICAL  SURGERY 


i.  Clamping  the  uterine  arteries. — The  uterus  is  pulled 
well  down,  and  the  situation  of  the  uterine  arteries  felt 
with  the  thumb  and  index-finger  of  the  right  hand  (Fig.  131), 
after  which  the  portion  of  the  broad  ligament  containing 
them  is  clamped  with  pressure-forceps  (Fig.   146)  and  then 


Fig.   150. — Separating  the 
uterus. 


divided  with  scissors  (Fig.  147).     This  proceeding  is  repeated 
on  the  opposite  side. 

ii.  Clamping  the  ovarian  artery. — The  remaining  portion 
of  the  broad  ligament  on  either  side  containing  the  ovarian 
artery  and  Fallopian  tube,  together  with  the  round  and 
ovarian  ligaments,  is  then  secured  with  a  second  pair  of 
long-bladed   pressure-forceps    (Fig.    148),    after   which    the 


VAGINAL  HYSTERECTOMY  257 

uterus  is  cut  free  on  that  side  (Fig.  149).  Fig.  150  shows 
the  same  details  being  carried  out  on  the  opposite  side, 
and  the  uterus  removed. 

iii.  Ligaturing  the  ovarian  artery. — The  pair  of  forceps 
which  is  clamping  the  ovarian  artery  and  upper  part  of 
the  broad  ligament  is  now  pulled  upon,  and  with  a  ligature 


Fig.  151. — Transfixing  the  top  of  the  broad  ligament. 

of  No.  4  silk  this  part  of  the  broad  ligament  is  transfixed 
and  tied  in  halves,  the  upper  passing  over  the  free  edge 
of  the  broad  ligament  and  securing  the  ovarian  artery, 
whilst  the  lower  retransfixes  the  cut  edges  of  the  broad 
ligament  below,  so  as  to  include,  when  it  is  tied,  the  round 
ligament  (Figs.  151-153).  The  opposite  side  is  treated 
in  the  same  way. 

R 


VAGINAL  HYSTERECTOMY 


259 


iv.  Ligaturing  the  uterine  artery. — The  forceps  clamp- 
ing the  uterine  artery  are  pulled  upon,  and  this  portion  of 
the  broad  ligament  is  ligatured  by  a  double  transfixion  or 
a  mattress-ligature  (Fig.  154)  ;  and  the  opposite  side  is 
treated  in  a  similar  manner  (Fig.  155) 


Fig.   154. — Transfixing  the  base  of  the  broad  ligament. 


III.   BY    THE   CLAMP   METHOD 

Instead  of  ligaturing  the  edges  of  the  broad  ligament 
after  the  uterus  has  been  removed,  some  operators  send 
the  patient  off  the  table  with  the  clamps  on.  This,  in  our 
opinion,  is  a  very  bad  operation.  We  have  seen  one  case 
which  nearly  had  a  fatal  result  from  the  slipping  of  the 


26o 


GYNECOLOGICAL   SURGERY 


forceps.  Moreover,  it  is  an  extremely  painful  method 
and  is  always  followed  by  considerable  sloughing  of  the 
clamped  tissues. 

If  by  reason  of  urgency  (for  the  method  has  the  advan- 


Fig.  155. — Securing  the  base  of  the  broad  ligament. 

tage  of  speed)  this  practice  is  followed,  the  clamps  should 
not  be  removed  until  at  least  forty-eight  hours  have 
expired. 


CHAPTER    XII 

RADICAL    HYSTERO- VAGINECTOMY    BY 
PARAVAGINAL    SECTION 

Indications. — This  operation  has  been  extensively  per- 
formed by  Schauta  and  other  Continental  surgeons  as  a 
routine  treatment  for  carcinoma  of  the  cervix.  We  have 
discussed  fully  its  merits  in  the  chapter  dealing  with  the 
radical  abdominal  operation  for  this  disease  (Chapter  xvn). 

We  ourselves,  while  preferring  the  abdominal  route  for 
most  cases  of  carcinoma  of  the  cervix,  are  of  opinion  that 
the  vaginal  route  should  be  chosen  where  the  patient  is 
very  fat.  Further,  we  have  employed  this  operation  for 
cases  of  carcinoma  of  the  body  of  the  uterus  with  meta- 
static growth  in  the  vagina  where  the  uterus  is  freely  mov- 
able and  there  are  no  signs  of  any  other  extension  of  the 
disease.  It  is  also. indicated  in  certain  cases  of  primary 
carcinoma  of  the  vagina. 

Preparation  of  the  patient. — See  pp.  82-84. 

Instruments. — The  same  as  for  vaginal  hysterectomy 
(p.  227). 

Operation. — The  following  are  the  steps  of  the  pro- 
cedure : — 

i.  Separation  of  the  lower  two  inches  of  the  vagina. — 
An  incision  is  made  round  the  mucous  membrane  of  the 
vagina,  at  its  junction  with  the  vulva,  with  a  pair  of  sharp 
angular  scissors  (Fig.  156),  after  which  this  canal  is  freed 
for  its  lower  two  inches  with  forceps  and  scissors  (Fig.  157). 

ii.  Closing  the  vagina. — The    cut    edges   of   the    vagina 

are    now    closely    approximated    with   interrupted   sutures 

of  No.  4  silk,  by  which  means  the  canal  is  closed  (Fig.  158). 

iii.  Separation     of   the    lateral    and     posterior    vaginal 

261 


262 


GYNECOLOGICAL  SURGERY 


walls. — The    remaining    portion    of    the    vagina    is     next 
separated   from  the  rectal  wall   with  the  scissors  and  the 


Fig.   156. — Hystero-vaginectomy  :    Incising  the  vagino- 
cutaneous  junction. 

pressure  of  a  swab  held  on  the  index-finger  of   the  right 
hand,    the    vagina    being    pulled    forwards    or    backwards 


Fig.   157. — Separating  the  lower  part  of  the  vagina. 


RADICAL  HYSTERO  VAGINECTOMY      263 

as  may  be  convenient,  by  means   of  the  ligatures  held  in 
the  left  hand  (Fig.  159). 


Fig.   158. — Closing  the  vagina. 


iv.  Paravaginal  section. — The  separated  vagina  being 
now  held  right  forwards  by  means  of  a  broad  retractor,  a 
deep  incision  is  made  with  a  scalpel  along  the  length  of 


Fig.   159. — Separating  the  vagina  from  the  rectum. 


264 


GYNECOLOGICAL  SURGERY 


the  vaginal  bed  on  its  left  side  and  through  the  skin 
to  the  left  side  of  the  rectum  and  around  it  towards  the 
coccyx,  the  anterior  fibres  of  the  levator  ani  being  divided, 
with  the  result  that  the  wound  gapes  to  a  marked  degree, 
and  sufficient  room  is  obtained  for  further  manipulations 
(Fig.   160). 


Fig.  160. — Making  the  paravaginal  incision. 


This  incision  may  give  rise  to  very  brisk  haemorrhage, 
which  must  be  arrested  by  ligaturing  any  individual  vessels 
that  are  seen  spouting,  or  applying  mattress-sutures  to 
any  surfaces  where  there  is  marked  oozing. 

v.  Opening  the  recto-uterine  pouch. — Auvard's  specu- 
lum is  now  inserted  into  the  wound,  and,  the  vagina  being 
held   forwards   by   the   assistant,   the   peritoneal   reflection 


RADICAL  HYSTERO  VAGINECTOMY      265 

at  the  bottom  of  Douglas's  pouch  is  seized  with  pressure- 
forceps  and  snicked  through  with  scissors  (Fig.  161),  after 
which  a  large  swab  with  a  tape  affixed  is  placed  in  Douglas's 
pouch  to  prevent  the  bowels  from  prolapsing. 

vi.  Separating    the    bladder    and    opening    the     utero- 
vesical    pouch. — The  vagina  being  held   well   back  by  an 


Fig.   161. — Opening  the  recto-uterine  pouch. 

assistant,  the  bladder  is  separated  by  a  few  judicious 
snips  with  the  scissors  (Fig.  162),  aided  by  the  handle  of 
the  scalpel  and  swab  pressure  (Fig.  163),  until  the  ureters 
come  into  view.  These  should  now  be  separated  as  far 
as  possible  with  the  index-finger  from  the  paravaginal 
and  para-uterine  tissue.  The  identification  and  separation 
of  the  ureters  is  rendered  more  easy  if  the  bladder  be  well 


266 


GYNECOLOGICAL  SURGERY 


separated  laterally.  A  broad  retractor  is  now  hooked 
under  the  bladder,  which  is  dragged  against  the  pubes, 
and  the  utero-vesical  reflection  of  peritoneum  having  been 
seized  with  pressure-forceps,  the  pouch  is  opened  with 
scissors  (Fig.    164). 

vii.  Ligature     of    the     uterine     vessels. — An    assistant 


Fig.   162. — Separating  the  bladder. 


pulls  the  vagina  well  over  to  the  right  side  of  the  patient, 
and  while  another  holds  the  bladder  well  back  the  operator 
passes  the  index-finger  of  his  left  hand  behind  the  broad 
ligament,  identifies  the  uterine  artery,  and  passes  round 
it  a  Worrall's  needle  (Fig.  165)  to  which  a  piece  of  No. 
4  silk  is  attached.  The  needle  is  now  withdrawn,  and 
the  lower  portion  of  the  broad  ligament  containing  the 
uterine  vessels  is  ligatured,  the  uterus  being  then  severed 
by  scissors  from  that  portion  of  the  broad  ligament  already 
secured.     The  right  side  is  treated  in  the  same  way. 


RADICAL   HYSTERO  VAGINECTOMY 


267 


viii.  Delivering  the  fundus  of  the  uterus. — The  ante- 
rior retractor  having  been  removed,  the  operator  passes 
his  finger  into  Douglas's  pouch  and  anteflexes  the  fundus 
of  the  uterus  so  that  it  appears  below  the  bladder.  The 
fundus  is  then  caught  with  a  volsella  and  drawn  forwards 


Fig.   163. — Exposing  the  ends  of  the  ureters. 


so  that  the  upper  edges  of  the  broad  ligaments  come  into 
view  (Fig.  166). 

ix.  Ligature  of  the  ovarian  vessels  and  round  liga- 
ments.— The  anterior  retractor  is  again  pushed  up  below 
the  pubes,  this  time  above  the  fundus,  and  is  given  to  an 
assistant  to  hold,  whilst  a  second  assistant  with  a  pair 
of  strong  forceps  pulls  the  fundus,  together  with  the  ovary 
and  tube  of  the  left  side,  well  towards  the  right. 

The  operator  now  slips  his  left  index-finger  behind  the 
uncut  portion   of   the   broad   ligament   and  with  his  right 


;68 


GYNECOLOGICAL  SURGERY 


hand  passes  a  Worrall's  needle  over  the  upper  edge  of  the 
broad  ligament  and  then  through  it  (Fig.  167).  The  needle, 
having  been  threaded  with  No.  4  silk,  is  withdrawn,  the 
silk  divided,  and  the  ovarian  vessels  and  round  ligaments 
separately  secured  on  the  left  side. 


Fig.  164. — Opening  the 
utero-vesical  pouch. 


The  uterus  is  then  cut  free  on  the  left  side,  after  which 
the  right  side  is  treated  in  a  similar  way. 

x.  Suture  of  the  paravaginal  wound. — The  para- 
vaginal wound  is  now  closed  by  a  series  of  interrupted 
sutures,  fine  silk  being  used  for  the  vaginal  portion  and 
silkworm-gut  for  the  skin. 

Dressing. — The  swab  is  removed  from  Douglas's  pouch 
and  some  gauze  is  lightly  packed  into  the  wound  along 
its  whole  length. 


RADICAL  HYSTEROVAGINECTOMY      269 

After-treatment. — See  Chapter  xxxn.  The  gauze  pack- 
ing is  removed  in  -twenty-four  hours,  and  the  cavity  is 
lightly  packed  every  day  with  iodoform  gauze.  In  these 
cases,  much  sloughing  of  the  long,  narrow  wound  may 
take  place,  with  marked  fetor  and  a  certain  amount  of 


Fig.  165. — Transfixing  the  base  of  the  broad  ligament. 

constitutional  disturbance.  Should  this  occur,  the  cavity 
must  be  lightly  irrigated  with  a  solution  of  peroxide  of 
hydrogen,  10  volumes,  and  the  packing  changed  several 
times  a  day.  If  there  is  much  oedema  or  sloughing  of  the 
external  skin,  hot  fomentations  should  be  applied.  The 
bladder  must  be  catheterized  for  a  week  or  two,  and  washed 
out  twice  daily  with  boric-acid  solution.  Urotropin  or 
salol  may  be  given  by  the  mouth.  The  stitches  closing 
the  paravaginal  incision  externally  should  be  removed  in 


270  GYNECOLOGICAL  SURGERY 

a  week.  The  period  of  convalescence  will  be  a  long  one, 
owing  to  the  time  taken  for  the  cavity  to  close.  The 
epithelium  from  the  surface  tends  to  grow  inwards,  so  that 
eventually  a  short,  very  narrow  pseudo-vagina  may  be 
formed. 

Dangers    and    difficulties. — The    operation    is    a    very 
serious  one,  and  should  not  be  attempted  except  by  those 


Fig.   166. — Anteflexing  the  body  of  the  uterus. 

accustomed  to  vaginal  hysterectomy,  than  which  it  is 
much  more  difficult.  The  oozing  from  the  vaginal  bed 
and  paravaginal  incision  is  extremely  free,  and,  apart  from 
the  ligating  of  any  special  vessels,  the  operator  will  have 
to  rely  upon  the  pressure  of  the  retractors  to  keep  it  in 
check.  Great  care  must  be  exercised,  when  separating  the 
bladder  and  rectum,  to  avoid  injuring  these  structures. 
The   ureter    is   also   in  special   danger   of    being  wounded 


FIXATION    OF    UTERUS 


271 


unless  great  care  be  taken  to  define  it.     The  bowel  has  a 
special  tendency  to  prolapse. 

INTERVESICO-VAGINAL  FIXATION  OF  THE 
UTERUS 

Indications. — This  operation    should,  of    course,    never 
be  performed  on  a  woman  capable   of  child-bearing.     It 


Fig.  167. — Securing  the  ovarico-pelvic  ligament. 

was  devised  by  Freund  for  prolapse  of  the  uterus.  It  has 
been  highly  praised  by  some  authorities,  but  we  have 
not  performed  it  sufficiently  often  to  arrive  at  any  con- 
clusive judgment  as  to  its  merits  when  compared  with 
ventro-suspension  and  perineoplasty  for  this  condition. 
Preparation  of  the  patient. — See  pp.  82-84. 


272 


GYNAECOLOGICAL  SURGERY 


Instruments. — Those  for  vaginal  hysterectomy  (p.  227) ; 

but    eight    pressure-forceps    will    suffice,    and    in    addition 

silkworm-gut,  shot  and    coil,   and   a  shot  compressor  will 

be  required. 

Operation. — The  steps  of  the  procedure  are  as  follows  : — 
i.  Incising    the    anterior   vaginal    wall. — The   procident 

uterus  and  vagina  are  pulled   down  with  a  volsella  fixed 


Fig.   168. — Intervesico-vaginal  fixation  :    Denuding  the 
anterior  vaginal  wall. 

to  the  cervix,  and  the  anterior  vaginal  wall  is  put  upon  the 
stretch.  An  oval  area  is  delineated  by  two  curved  incisions 
beginning  just  under  the  urethra  and  terminating  at  the 
junction  of  the  vagina  and  cervix.  The  mucous  membrane 
of  the  vagina  corresponding  to  this  area  is  now  excised 
and  the  base  of  the  bladder  exposed  (Fig.  168). 

ii.  Separating    the    bladder     and     opening     the    utero- 
vesical    pouch. — The  bladder  is  separated  from  the  vaginal 


FIXATION   OF  UTERUS 


273 


Fig.    170. — Delivering 
the  uterus. 


274 


GYNAECOLOGICAL  SURGERY 


wall,  especially  laterally,  by  means  of  the  blunt-pointed 
scissors  and  swab  pressure  (Fig.  i6q),  and  the  peritoneum 
of  the  utero-vesical  pouch,  having  come  into  view,  is 
incised  transversely. 

iii.  Pulling  down  the  body  of  the  uterus. — The  vol- 
sella  having  been  removed  from  the  cervix,  the  body 
of   the    uterus    is    progressively    anteverted   by   successive 


Fig.   171. — The  sutures  applied. 

grips  of  its  anterior  wall  with  a  couple  of  volsellse 
until  the  fundus  in  its  most  dependent  portion  and  the 
whole  length  of  the  body  has  been  dislocated  into  a 
position  between  the  bladder  above  and  the  vagina  below 
(Fig.  170). 

iv.  Fixing  the  uterus  and  closing  the  vaginal  wound. — 
The  wound  in  the  anterior  vaginal  wall  is  now  closed 
by  interrupted  silkworm-gut  sutures  which  are  passed  so 
that  each  of  them  in  the  middle  of  the  deep  part  of  its 


FIXATION  OF  UTERUS  275 

course  picks  up  a  portion  of  the  anterior  uterine  wall 
(Fig.  171). 

The  uterus  is  thus  fixed  upside  down  with  its  anterior 
surface  parallel  to  and  in  contact  with  the  whole  length 
of  the  anterior  vaginal  wall. 

The  operation  should  be  concluded  by  a  perineoplasty 
on  the  lines  indicated  on  pp.  109-24. 

Dressing  and  after-treatment.  —  See  Chapter  xxxn. 
The  patient  should,  if  possible,  remain  in  bed  four  weeks, 
the  sutures  being  removed  on  the  tenth  day.  All  work 
involving  straining  should  be  avoided  for  at  least  three 
months. 


CHAPTER    XIII 

OPENING    AND    CLOSING   THE    ABDOMINAL 
CAVITY 

Instruments  required. — The  instruments  generally  required 
for  abdominal  operations  are  the  same  in  all  cases.  It 
will  be  convenient,  therefore,  to  set  them  forth  in  a  list 
to  which  the  reader  will  be  subsequently  referred.  Where 
any  special  instrument  is  required  it  will  be  mentioned  at 
the  beginning  of  the  section. 

A  scalpel. 

Four  short  and  two  long  Spencer  Wells  pressure-forceps. 

Four  short  Kocher's  pressure-forceps. 

Two  ring  forceps. 

One  dissecting  forceps. 

One  volsella. 

Two  blunted-pointed  scissors. 

One  bladder-sound. 

Berkeley's  self-retaining  retractor. 

Six  curved  needles  (Bonney's — two  No.  5,  two  No.  9, 
two  No.  13). 

One  straight  4-in.  needle,  or  Michel's  clip  apparatus. 

Three  reels  of  silk,  Nos.  1,  2,  and  4. 

Rubber  drainage-tube,  two  sizes,  J  inch  and  f  inch. 

A  rubber  catheter. 

Opening  the  abdominal  cavity. — The  following  are  the 
steps  of  this  procedure  : — 

i.  Skin-incision. — The  length  of  the  skin-incision  must 
necessarily  depend  both  on  the  size  of  the  tumour  and 
on  the  amount  of  fat  in  the  abdominal  wall.  In  an  average 
case  it  measures  about  5  inches,  and  is  situated  between 
the  umbilicus  and  the  pubis  in  the  mid-line.     Preparatory 

276 


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OPENING  ABDOMINAL  CAVITY 


277 


to  this  incision  the  operator  steadies  the  abdominal  wall 
with  his  left  hand,  the  thumb  resting  on  the  right  of  the 
median  line  and  the  fingers  on  the  left  (Fig.  172),  while 
with  his  right  hand  he  delineates  the  upper  border  of  the 
symphysis  pubis  to  ensure  that  the  lower  end  of  the  incision 
shall  not  be  carried  too  far.  It  may  be  necessary  to  clamp 
a  few  bleeding-points,  and  notably  two  may  require  ligature 
owing  to  the  division  of  a  small  transverse  artery  three- 
quarters  of  an  inch  above  the  symphysis  pubis. 


Fig.  172.— Opening  and  closing  the  abdomen  :  Incising 
the  skin. 


This  oozing  from  the  cut  edges  will  be  more  marked 
if  the  patient  is  exsanguinated  from  any  cause,  if  the 
tumour  is  or  has  been  inflamed,  if  it  is  of  a  malignant 
nature,  or  if  the  patient  is  taking  ether  and  is  much 
cyanosed. 

ii.  Fascial  incision. — The  linea  alba  is  next  incised 
(Fig.  173),  and  a  streak  of  fat  should  mark  the  interrectal 
space.  If  this  line  of  demarcation  should  not  be  ap- 
parent, search  must  be  made  for  it  to  one  or  other 
side  of  the  incision,  and  when  found  the  recti  should  be 


278 


GYNECOLOGICAL  SURGERY 


separated  for  the  entire  length  of  the  incision  by  placing 
the  forefinger  of  each  hand  in  the  wound  and  abducting 
them  (Fig.  174).  An  alternative  method  is  to  incise  the 
sheath  of  the  rectus  and  cut  directly  through  the  muscle, 
or  separate  the  fibres  by  inserting  the  points  of  the  scissors 
between  them,  which  is  perhaps  the  better  method,  as  it 

does  not  cause  so  much 
oozing.  Those  surgeons 
who  divide  the  muscle- 
layer  by  these  means 
do  so  either  because 
they  think  there  is  less 
chance  of  a  resulting 
hernia,  or  because  on 
failing  to  find  the  line 
of  separation  when  first 
incising  the  fascia  they 
will  not  trouble  to  seek 
for  it  further.  With 
regard  to  the  fear  of 
a  subsequent  hernia,  we 
do  not  think  this  need 
be  considered,  since  we 
have  known  hernia  oc- 
cur after  both  methods. 
And  we  are  further  of 
opinion  that  there  is 
a  distinct  disadvantage  in  cutting  through  the  muscle, 
since  not  only  is  there  apt  to  be  a  good  deal  of  trouble- 
some oozing  from  the  torn  vessels,  but  also  the  incision 
cannot  be  so  satisfactorily  retracted,  and  the  complaint 
of  pain  in  the  abdominal  wound  during  the  first  few  days 
after  the  operation  is  more  marked. 

In  some  cases,  on  incising  the  linea  alba  and  separating 
the  recti,  one  or  two  veins  running  transversely  from  under 
the  posterior  layer  of  the  sheath  will  be  divided,  and  the 
cut  ends  will  need  ligature. 


Fig.   173. — Incising  the  fascia. 


OPENING  ABDOMINAL  CAVITY 


279 


iii.  Peritoneal  incision. — After  the  recti  and  sub- 
peritoneal fat  have  been  separated  by  the  index  fingers,  the 
shiny  peritoneum  appears,  and  in  most  cases  no  difficulty 
is  experienced  in  its  recognition,  since  the  urachus  can  be 
seen  as  a  white  cord  running  through  this  membrane. 

The  peritoneum  is  now  clamped  on  the  left  of  the  median 
line  with  pressure-forceps  which  are  handed  to  the  assistant, 
or  the  assistant  may 
clamp  it  himself,  whilst 
on  the  right  of  the 
median  line  the  sur- 
geon holds  the  perito- 
neum with  a  pair  of 
dissecting  forceps. 

The  peritoneum  is 
then  stretched  between 
the  forceps,  slightly 
raised,  and  carefully 
nicked  so  that  air  can 
enter  and  displace  any 
intestines  or  omentum 
that  may  be  adhering 
to  it,  and  which  other- 
wise, if  a  deliberate  in- 
cision were  made,  might 
be  wounded  (Fig.  175). 
An  additional    method 

of  obviating  this  risk  is  to  give  that  piece  of  peritoneum 
which  is  held  by  the  dissecting  forceps  a  little  shake 
before  nicking  it,  when  any  adhering  intestine  or  omen- 
tum will  fall  away. 

The  abdominal  cavity  having  been  opened,  the  peri- 
toneum is  divided  along  the  entire  length  of  the  wound 
towards  the  lower  angle  by  inserting  under  the  peritoneum 
the  first  and  second  fingers  of  the  left  hand,  palmar  surface 
uppermost  (Fig.  176),  and  cutting  between  the  two  ;  and 
towards  the  upper  angle  by  raising  it  with  the  index  finger 


Fig.   174. — Separating  the  recti. 


280 


GYNECOLOGICAL  SURGERY 


of  the  left  hand,  palmar  surface  uppermost,  directing  the 
assistant  to  do  likewise  on  his  side,   and  then  cutting  it 


Fig.   175. — Incising  the  peritoneum. 


Fig.     176. —  Enlarging     the 
wound  towards  the  pubes. 


(Fig.  177),  in  each  case  avoid- 
ing the  veins  which  at  times 
are  found  running  vertically 
towards  the  pubis. 

If  there  appears  to  be  any 
danger  of  wounding  the  bowels 
or  omentum  during  this  divi- 
sion, a  swab  may  be  placed 
over  them   first. 

Difficulties  and  dangers. — 
Sometimes,  after  the  recti  have 
been  separated,  difficulty  will 
be  experienced  in  recognizing 
the  peritoneum,  or  in  making 
an  opening  into  its  cavity, 
whilst  in  some  cases  there  is 
a  danger  of  wounding  the 
subjacent  organs.     There  may 


OPENING  ABDOMINAL  CAVITY 


281 


be  several  reasons  for  this,  which  will  be  discussed  under 
the  following  headings  : — 

i.  Subperitoneal  fascia. — In  certain  cases,  when  the 
peritoneum  is  adherent  to  an  underlying  tumour,  the  deeper 
layers  of  the  subperitoneal  fascia  may  be  mistaken  for 
the  peritoneum,  while  the  peritoneum  is  mistaken  for  the 
surface  of  the  tumour,  and  under  these  conditions  the 
surgeon,  thinking  that  the  tumour  is  adherent  to  the  peri- 
toneum, may  endeavour  to  separate  it,  and  will  in  reality 


Fig.   177. — Enlarging  the  wound  towards  the  umbilicus. 


be  stripping  the  peritoneum  itself  from  the  subperitoneal 
tissue.  It  is  then  of  use  to  remember  that  at  the  umbilicus 
the  peritoneum  and  subperitoneal  tissue  cannot  be  separated. 
ii.  Bladder. — This  organ  may  be  so  distended  or  dragged 
upon  by  the  tumour  that  it  reaches  half-way  up  the  wound, 
or  even  higher,  and,  if  it  is  not  at  first  recognized,  difficulty 
will  be  experienced  in  attempting  to  open  the  peritoneal 
cavity.  Suspicion  may  be  aroused  on  discovering  that  the 
tissue  presenting  after  separation  of  the  recti  has  a  fleshy 
appearance  differing  from  that  of  the  shiny  membranous 
peritoneum,  and  also  that  when  a  small  cut  is  made  into 
it  marked  venous  oozing  occurs,  an  almost  sure  sign  that 


282  GYNECOLOGICAL  SURGERY 

the  bladder  is  being  wounded.  This  difficulty  and  danger 
may  often  be  avoided  by  inquiring  of  the  nurse,  before  any 
abdominal  operation,  whether  she  has  found  any  difficulty 
in  catheterizing  the  patient,  an  answer  in  the  affirmative 
being  a  forewarning. 

If  there  is  reason  to  suspect  that  the  presenting  tissue 
is  bladder,  the  attempt  to  open  the  peritoneal  cavity  at 
that  point  should  be  abandoned,  and  a  point  nearer  to  the 
umbilicus  should  be  selected.  In  the  more  difficult  cases 
a  sound  should  be  passed  into  the  bladder  to  settle  the 
matter. 

The  bladder  has  often  been  mistaken  for  subperitoneal 
fascia  or  peritoneum  by  the  unobservant  operator,  and 
consequently  opened.  This  mistake  may  be  avoided  by 
bearing  in  mind  the  advice  given  above.  The  bladder  may 
also  be  wounded  when  the  peritoneal  opening  is  being 
enlarged  towards  its  lower  end  (Fig.  176),  which  accident 
may  be  prevented  by  holding  up  the  peritoneum  and 
looking  at  it  through  its  inner  surface,  when  the  limitation 
of  its  transparency  will  indicate  the  position  of  the  bladder. 
If  the  bladder  is  opened,  it  should  be  at  once  closed 
according  to  the  methods  described  elsewhere   (p.   539). 

iii.  Intestine  or  omentum. — If  the  intestines  are  much 
distended  with  gas,  if  they  or  the  omentum  are  adherent 
to  the  parietal  peritoneum,  or  if  both  are  floated  up  by 
free  fluid  in  the  peritoneal  cavity,  there  is  danger,  unless 
care  be  exercised,  that  one  or  other  will  be  injured  when 
the  peritoneum  is  incised.  When  it  appears  that  any  of 
these  conditions  may  be  present,  only  the  smallest  nick 
should  be  made  at  first  in  the  peritoneum,  and  that  very 
carefully.  If  the  air  does  not  then  sufficiently  separate 
the  peritoneum  from  the  abdominal  contents,  the  opening 
must  be  carefully  enlarged  with  a  blunt-pointed  director 
until  a  finger  can  be  inserted  and  any  adhesions 
separated,  fluid  evacuated,  or  a  swab  introduced  between 
the  peritoneum  and  bowel,  as  the  case  may  be.  If  the 
omentum  is  wounded  the  bleeding-points  must  be  ligatured 


OPENING  ABDOMINAL  CAVITY  283 

at  once  with  thin  silk,  or  if  the  intestine  is  injured  it  should 
be  sutured  according  to  the  directions  given  elsewhere. 

iv.  Adherent  tumour. — The  tumour  may  be  adherent 
to  the  parietal  peritoneum.  In  the  case  of  an  ovarian  cyst 
which  has  been  inflamed  and  then  become  adherent  to  the 
parietal  peritoneum,  there  will  be  at  times  some  difficulty 
in  distinguishing  the  one  from  the  other.  We  have  known 
cases  where  the  peritoneum,  having  been  mistaken  for 
the  cyst-wall,  has  been  stripped  off  the  parietes  nearly 
up  to  the  diaphragm  before  the  error  was  discovered, 
with  the  result  that  sloughing  took  place  at  a  later  date. 

To  determine  between  peritone'um  and  cyst-wall  may 
test  the  powers  of  even  the  most  experienced,  and  the 
only  way  to  obviate  this  danger  is  to  remember  that 
the  condition  just  described  may  exist,  and  when,  as  in 
this  or  in  any  other  case,  there  appears  to  be  difficulty 
in  opening  the  abdominal  cavity,  to  try  again  at  a 
higher  point  of  the  incision. 

Size  of  opening  in  abdominal  wall. — It  is  important 
that  the  opening  in  the  abdominal  wall  should  be  sufficiently 
large  to  deliver  the  tumour  and  to  enable  one  to  obtain  a 
good  view  of  the  pelvic  organs.  There  is  a  great  tendency 
for  most  beginners,  and  even  for  many  veterans,  to  make 
this  opening  too  small.  As  a  result,  any  complications  that 
present  themselves  are  much  more  troublesome  to  deal 
with,  and  the  operator  loses  much  valuable  time  niggling 
about  in  a  confined  space,  only  to  be  compelled  in  the  end 
to  enlarge  the  opening. 

There  is  no  greater  tendency  to  a  ventral  hernia  with 
a  large  opening  than  with  a  small  one,  and  the  operator 
will  be  well  advised  in  making  his  first  incision  of  ample 
length. 

The  exact  length  depends  upon  the  circumstances 
with  which  he  has  to  deal.  In  the  case  of  solid  tumours 
the  upper  end  of  the  incision,  as  a  general  rule,  should  be 
at  least  2  inches  above  the  upper  end  of  the  tumour. 
If,  however,  the  tumour  be  very  large,  or  there  be  doubts 


284  GYNAECOLOGICAL  SURGERY 

as  to  its  removability,  or  its  exact  location,  it  is  better 
to  begin  with  an  incision  large  enough  only  for  adequate 
examination,  and  to  enlarge  it  or  not  as  the  ascertained 
nature  of  the  case  may  demand. 

Similarly  in  large  fluid  tumours,  some  of  which  are  with 
advantage  tapped  before  removal,  it  is  advisable  to  begin 
with  a  moderate  incision.  It  is  lamentable  to  see  the 
abdomen  split  from  ensiform  to  pubis  for  a  tumour  which 
subsequent  examination  shows  could  have  been  properly 
removed  through  a  wound  a  third  the  length.  In  obese 
patients  the  size  of  the  wound  must  be  relatively  large, 
while  in  those  with  thin  or  flaccid  abdominal  walls  a  much 
smaller  opening  will  suffice. 

In  all  operations  requiring  deep  dissection  at  the  bottom 
of  the  pelvis,  such  as  the  radical  abdominal  operation  for 
carcinoma  of  the  cervix,  a  free  incision  of  the  abdominal 
wall  must  be  made. 

If  it  is  necessary  to  pass  the  umbilicus  when  enlarging 
the  wound  upwards,  it  is  good  practice  to  carry  the  incision 
around  and  not  through  this  structure.  There  are  three 
good  reasons  for  this  : 

i.  The  skin  there  is  with  difficulty  rendered  sterile. 

2.  The  various  layers  of  the  abdominal  wall  fusing  at 
that  point,  it  is  impossible  to  effect  there  a  satisfactory 
three-tiered  suture  when  closing  the  abdominal  wall. 

3.  Owing  to  the  thinness  of  the  tissues  and  the  down 
dip  of  the  skin,  buried  sutures  are  more  likely  to  cause 
suppuration  in  that  situation.  This  is  the  more  disastrous 
if  a  continuous  peritoneal  suture  has  been  employed,  since 
the  wound  will  suppurate  deeply  along  its  whole  length. 

In  enlarging  the  wound  downwards,  the  linea  alba 
may  be  incised  right  down  to  the  bone,  but  the  peritoneum 
should  not  be  divided  lower  than  a  point  an  inch  above 
the  pubis.  Apart  from  the  possibility  of  wounding  the 
bladder,  such  a  proceeding  has  the  disadvantage  of  freeing 
this  viscus  to  such  an  extent  that  it  drops  down  upon 
the    uterus    and   continually    obscures   the   surgeon's   view 


CLOSING  ABDOMINAL  WOUND  285 

throughout  the  operation.     This   is  especially  baulking  in 
deep  operations  in  fat  patients. 

Closing  the  abdominal  wound. — This  is  effected  in  the 

following  stages  : — ■ 

i.  Peritoneum. — The  peritoneum  is  united  by  a  con- 
tinuous suture  of  No.  2  silk.  The  assistant  should  elevate 
the  peritoneal  edges  by  means  of  two  pressure-forceps, 
one  applied  at  each  end  of  the  incision. 


Fig.   178. — Suturing  the  peritoneum. 

After  the  first  stitch  is  tied.,  he  removes  the  forceps  at 
that  end,  and,  maintaining  his  hold  of  the  other,  employs 
his  free  hand  in  holding  the  thread  taut,  so  as  to  prevent 
its  slipping  during  the  insertion  of  each  stitch.  If  the 
bowels  are  troublesome  and  bulge  into  the  wound,  so  that 
they  are  in  danger  of  being  pricked,  a  small  swab  may  be 
placed  over  them  before  the  suturing  is  started,  care  being 
taken,  of  course,  to  leave  an  opening  sufficiently  large  to 
remove  the  swab  before  the  layer  is  completely  sutured. 
At  times,  after  removal  of  this  suture-swab,  much  difficulty 


286 


GYNECOLOGICAL  SURGERY 


may  be  found  in  closing  the  small  opening  that  remains, 
on  account  of  the  intestine  bulging  through  the  opening. 
This  difficulty  will  be  successfully  surmounted  if  the  cut 
edges  of  the  peritoneum  are  lifted  as  high  as  possible  with 
two  pairs  of  forceps  and  the  suture  is  passed  during  ex- 
piration, or  by  passing  the  forefinger  of  the  left  hand  into 
the  wound,  depressing  the  gut,  and  then  suturing  above  the 
finger  and  drawing  the  silk  tight  as  the  finger  is  removed. 
It  is  best  to  commence  suturing  this  layer  at  the  umbilical 


Fig.   179. — Suturing  the  fascia. 

end  of  the  incision,  because  (i)  it  is  the  more  difficult  end, 
especially  in  fat  patients  ;  and  (2)  if  a  suture- swab  is  being 
used,  its  withdrawal  will  not  then  disturb  the  omentum 
(Fig.  178). 

ii.  Fascia. — The  fascial  edges  are  united  with  inter- 
rupted No.  4  silk  sutures  on  curved  needles,  beginning  at  the 
pubic  end  of  the  wound  (Fig.  179).  As  each  suture  is  tied 
it  is  handed  to  the  assistant,  who  pulls  it  tightly  towards 
the  pubis,  thus  putting  the  fascial  edges  on  the  stretch 
and  defining  them.     As  the  following  suture  is  tied  he  cuts 


CLOSING  ABDOMINAL  WOUND  287 

the  suture  he  is  holding,  just  above  the  knot,  and  then 
takes  hold  of  the  next  one. 

If  the  abdominal  incision  has  been  carried  above  the 
navel,  it  may  be  found  impossible  to  suture  the  fascia  and 
peritoneum  separately,  since  the  two  may  be  so  adherent 
there  as  to  form  practically  only  one  layer.  In  such  cases 
the  peritoneum  and  fascia  above  the  navel  are  sutured 
together  with  interrupted  silk  sutures,  care  being  taken 
when  passing  the  highest  sutures  that  neither  the  colon 
nor  the  stomach  is  transfixed. 

In  some  cases,  especially  when  the  sutured  peritoneum 
is  loose  and  falls  away  markedly  from  the  fascia  at  the 
pubic  end  of  the  wound,  it  is  a  good  plan  to  pass  one 
or  two  sutures  through  both  peritoneum  and  fascia,  thus 
bringing  the  two  into  apposition  and  closing  the  potential 
space  into  which  blood  might  ooze  and  cause  a  haema- 
toma.  Some  surgeons  prefer  to  pass  these  "haemostatic" 
sutures  through  all  three  layers,  including  the  skin. 

iii.  Skin. — The  skin-incision  may  be  closed  either  by 
suture  or  by  means  of  Michel's  clips. 

If  suturing  is  preferred,  a  simple  continuous  suture  of 
No.  2  silk  on  a  straight  4-in.  needle  should  be  adopted,  care 
being  taken  to  oppose  the  edges  accurately,  for  otherwise 
healing  may  be  less  perfect  (Fig.  180).  While  suturing  the 
skin  a  vein  may  be  pricked,  and  oozing  rather  more  than 
can  be  neglected  take  place.  As  a  rule,  this  is  at  once 
stopped  by  tightening  the  suture,  but  if  not,  a  pair  of 
pressure-forceps  should  be  applied  to  the  oozing  spot 
for  a  few  minutes,  or  a  mattress-suture  passed  under- 
neath it. 

When  the  incision  is  carried  above  the  navel,  it  is  often 
better,  if  this  structure  is  at  all  depressed,  to  approximate 
the  skin-edges  in  its  neighbourhood  by  one  or  two  inter- 
rupted sutures  of  silk,  since  they  can  be  more  easily  removed 
than  the  continuous  stitch. 

In  exceptional  circumstances,  such  as  extreme  flab- 
biness    of    the    abdominal    wall,    or    where    post-operative 


288 


GYNECOLOGICAL  SURGERY 


bronchitis  is  anticipated,  it  is  good  practice  to  reinforce 
the  three-tier  suture  described  by  a  few  through-and- 
through  interrupted  silk  sutures.  Two  of  these  sutures 
are  with  advantage  inserted  on  either  side  of  a  drainage 
track,  so  as  to  close  the  planes  of  the  abdominal  wall  and 
prevent  suppuration  from  extending  along  them. 

By  far  the  better  method  of  closing  the  skin,  in  our 
opinion,  is  by  Michel's  clips.  The  advantages  of  this 
clever  device  may  be  thus  summarized  : — 

(i)  It   is   to   be    remembered   that   every   suture   pene- 


Fig.   180. — Suturing  the  skin. 


trating  the  skin  is,  in  fact,  a  seton.  Both  during  its  insertion 
and  its  removal,  particles  of  epidermis,  possibly  infected, 
tend  to  be  implanted  in  the  underlying  connective  tissue, 
while  during  the  whole  of  its  tenure  a  potential  track  for 
the  downgrowth  of  organisms  is  created.  We  believe  that 
many  stitch-abscesses  have  their  origin  thus.  Michel's 
clips,  since  they  do  not  penetrate  the  thickness  of  the 
skin,  are  free  from  this  objection. 

(2)  Owing  to  the  broad  surface  of  contact  effected  by 
the  clips,   a  peculiarly  strong  union  occurs,  so  that  they 


CLOSING  ABDOMINAL  WOUND 


289 


may   be  safely  removed  three   days   after   the   operation. 
This  is  a  great  relief  to  the  patient. 

(3)  They    can    be    inserted    more     quickly    than   the 
quickest  method  of  suture. 

(4)  The  subsequent  scar  is  very  narrow  and  no  stitch- 
hole  scars  are  left.  Moreover,  the  scar  does  not  tend 
to  adhere  to  the 
fascia  and  become 
depressed.  This 
may  seem  a  small 
matter  in  a  situa- 
tion like  the  ab- 
domen, but  in  our 
experience  many 
women  are  very 
sensitive,  and  na- 
turally so,  of  an 
unsightly  seam 
disfiguring  the  na- 
tural curve  of  the 
abdominal  wall. 

(5)  If  there  is 
any  bleeding  from 
the  wound  after 
the  operation  is 
over,  the  blood 
escapes  between 
the  clips,  therefore 

the  troublesome  complication  of  a  hematoma  is  avoided. 
Since  we  have  used  Michel's  clips  we  have  seen  this  com- 
plication very  rarely. 

Application  of  Michel's  clips.— The  pubic  angle  of  the 
wound  is  seized  with  the  forceps  in  the  right  hand,  and  the 
skin  edges  are  approximated  with  the  clip-holder  in  the 
left  hand,  about  half  an  inch  above  it  (Fig.  181).  The 
lower  edges  of  the  incision  are  then  pulled  taut  by  making 
traction  with  the  clip-holder  in  an  upward  direction,  and 

T 


Fig.   181.— Technique  of  Michel's  clips  : 
Approximating  the  skin-edges. 


2Q0 


GYNECOLOGICAL  SURGERY 


with  the  forceps  in  the  right  hand  the  surgeon  removes  a 
clip  from  the  holder  (Fig.  182),  and   clips   the  skin-edges 


Fig.   182.— Seizing  the 
clip. 


Fig.  183.— Continuing  the 
approximation. 


just  above  the  lower  angle  of  the  incision  (Fig.  183).     He 
now,  without  letting  go  of  the  clip  he  has  inserted,  makes 

traction  pubicwards  on 
the  forceps  holding  it, 
and  thus  renders  taut 
the  ununited  skin-edge 
adjoining,  which  is  again 
approximated  with  the 
clip-holder  about  half 
an  inch  from  the  clip 
that  has  been  fixed. 
Traction  is  made  with  the  clip-holder  in  the  opposite  direc- 
tion while  another  clip  is  removed  and  fixed,  and  so  on. 


Fig.  183a. — Method  of  removing 
clip. 


CLOSING  ABDOMINAL  WOUND  291 

Removal  of  sutures  and  clips. — Skin-sutures  should  be 
removed  on  the  seventh  day  after  the  operation,  except 
in  the  case  of  through-and-through  sutures,  which  may 
be  left  in  situ  a  day  or  two  longer  if  the  surgeon  thinks 
necessary.  If  Michel's  clips  have  been  used,  they  should 
be  removed  on  the  fourth  day.  The  clips  are  easily  re- 
moved by  means  of  the  special  forceps  figured  on  p.  18. 
The  clip  having  been  steadied  by  forceps  held  in  the 
left  hand,  the  beak  of  the  removal  forceps  is  inserted 
under  the  clip,  which  is  then  opened  out  and  removed 
(Fig.  183a).  A  narrow  strip  of  gauze  along  the  wound  and 
one  or  two  bands  of  adhesive  strapping  are  then  applied. 


CHAPTER    XIV 

SUBTOTAL  HYSTERECTOMY  BY  THE  ROUTINE 
CLAMP   AND    LIGATURE    METHODS 

Indications — This  and  the  method  next  to  be  described 
are  the  ordinary  ways  of  performing  subtotal  hysterectomy. 
The  technique  is  indicated  in  all  conditions  in  which  the 
body  of  the  uterus  is  either  movable  or,  being  adherent, 
can  be  freed  ;  and  in  which  the  broad  ligaments  and  supra- 
vaginal cervix,  beyond  being  elongated,  are  not  deformed 
by  the  presence  in  them  of  a  tumour. 

These  are  not  the  correct  methods  of  performing  subtotal 
hysterectomy  for  myomata  of  the  supravaginal  cervix  or 
broad  ligament,  nor  for  those  cases  in  which  the  top  of 
the  uterus  is  tethered  down  by  adhesions  that  cannot 
readily  be  divided.  For  such  cases  the  methods  described 
a^  PP-  338,  406  and  331  are  properly  to  be  employed. 

I.    SUBTOTAL    HYSTERECTOMY   BY  THE   CLAMP 

METHOD 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments — See  p.  276. 

Operation. — The  following  are  the  steps  of  the  pro- 
cedure : — 

i.  Opening  the  abdominal  cavity. — See  p.  276. 

ii.  Delivering  the  uterus. — If  the  uterus  is  the  seat 
of  a  tumour,  the  surgeon  slips  his  left  hand  into  the  abdo- 
minal cavity  under  it,  and  while  he  is  lifting  it  through  the 
wound  his  right  hand  assists  in  retracting  the  parietes  on 
the  right  side,  the  assistant,  if  necessary,  doing  likewise 
on  the  left.  If  the  uterus  is  not  enlarged,  it  cannot,  except 
in  thin  women  with  very  lax  tissues,  be  brought  outside 

292 


Plate  III.— Multiple  Myomata  of  the  Uterine  Body. 


SUBTOTAL   HYSTERECTOMY 


293 


the    abdominal     wound.      Delivery    may    be    assisted    by 
traction  on  a  volsella  fixed  on  the  uterus   (Fig.  184). 

iii.  Inserting  the  large 
swab. — When  the  tumour 
has  been  delivered,  the 
intestines  and  omentum 
are  covered,  and  prevented 
from  protruding  through 
the  abdominal  opening  or 
into  the  field  of  operation, 
by  packing  the  largest  flat 
swab  well  up  under  the 
abdominal  wall,  and  then 
turning  the  lower  edge 
down  into  Douglas's  pouch 
(Fig.  185). 

iv.  Clamping  and  divid- 
ing the  ovarian  vessels. — 
Two  pressure  -  forceps  are 
now  applied  to    the    upper 


Fig.  184. — Routine  subtotal 
hysterectomy  :  Delivering 
the  uterus. 


Fig.   185. — Inserting  the  large  swab. 


294 


GYNAECOLOGICAL  SURGERY 


border  of  the  broad  ligaments  on  each  side.  Their  exact 
position  will  depend  upon  whether  the  ovaries  are  healthy, 
and  whether  they  are  going  to  be  conserved  or  not. 

If  the  ovaries  are  healthy,  they  should  always  be  con- 
served, and  in  this  case  the  forceps  will  be  applied  between 
the  uterus  and  the  ovary.  One  pair  of  forceps  on  each 
side  clamps  the  tube,  and  as  much  mesometrium  as  possible, 
including  the  ovarian  vessels,  close  to  the  uterus,  while  the 
other  pair  is  applied  in  a  similar  manner  an  inch  nearer  the 
ovary  (Fig.  186). 


Fig.   186. — Clamping  the  top  of  the  broad  ligament. 


It  is  necessary  to  clamp  a  good  inch  of  mesometrium, 
since  the  ovarian  artery  does  not  run  close  under  the  tube. 
Pressure-forceps  with  blades  half  as  long  again  as  the 
ordinary  ones  will  therefore  be  found  best  for  this  purpose, 
and  any  oozing  will  be  much  better  controlled.  If,  how- 
ever, it  has  been  decided  to  remove  the  ovaries,  then  the 
outer  pair  of  forceps  is  applied  to  the  ovarico-pelvic  liga- 
ment outside  the  ovary. 

The  forceps  being  applied,  the  upper  part  of  the  broad 
ligament  and  the  tube  are  divided  just  inside  the  outer 
forceps. 


SUBTOTAL  HYSTERECTOMY 


295 


v.  Clamping  and  dividing  the  round  ligament. — The 
method  of  dealing  with  the  round  ligament  varies.  In  many 
cases  it  will  be  found  possible  to  secure  the  round  ligament 
with  the  same  pair  of  forceps  that  is  clamping  the  ovarian 
vessels  and  tube.  In  other  cases,  where  the  upper  portion 
of  the  broad  ligament  is  expanded  by  the  growth  of 
the   tumour,   it   will    be    necessary    to    clamp  the    round 


Fig.   187. — Dividing  the  top  of  the  broad  ligament. 


ligaments  separately.  Or  it  may  be  found  that  one 
forceps  will  suffice  to  secure  the  round  ligaments,  tubes, 
and  ovarian  ligament  as  they  come  off  the  cornu  of  the 
uterus,  whilst  further  out,  owing  to  the  separation  of  the 
broad  ligament,  separate  clamps  will  be  needed.  Or,  lastly, 
it  may  prove  to  be  necessary  to  clamp  the  round  ligament 
separately  on  account  of  its  size,  which  may  have  increased 
pari  passu  with  the  hypertrophy  of  the  rest  of  the  uterus. 
If  the  precaution  of  clamping  the  round  ligaments  is  not 


296 


GYNECOLOGICAL  SURGERY 


taken,  troublesome  oozing  due  to  their  retraction  after 
division  may  delay  the  suturing  of  the  stump  at  a  later 
period.  After  being  clamped,  the  round  ligaments  are 
divided. 

vi.  Opening  up  the  broad  ligaments. — The  broad  liga- 
ments are  further  divided  as  far  as  the  lower  limit  of  the 
avascular  space  which  lies  beneath  the  ovarian  and  round 
ligaments  (Fig.  187),  and  .are  then  opened  up  towards  the 


Fig.   188. — Opening  up  the  broad  ligament. 


uterus  by  hooking  the  forefinger  of  each  hand  between 
the  cut  edges  of  the  peritoneum  and  abducting  them, 
while  the  uterus  is  pulled  over  to  the  opposite  side  by 
the  assistant  so  as  to  bring  the  uterine  vessels  into  view 
(Fig.  188). 

vii.  Reflecting  the  anterior  flap  of  peritoneum. — The 
anterior  flap  of  peritoneum  is,  as  a  rule,  quite  easily  dis- 
sected off  the  lower  part  of  the  uterus  or  tumour  and 
turned  downwards.    Exactly  how  much  peritoneum  should 


SUBTOTAL  HYSTERECTOMY 


297 


be  deflected  is  a  matter  of  experience  rather  than  rule, 
but  sufficient  must  be  taken  to  cover  the  stump  later  on. 
When  in  doubt,  therefore,  it  is  better  for  the  operator  to 
take  too  much  than  too  little,  for  it  can  be  trimmed  easily, 
if  necessary,  and  peritoneal  flaps  always  shrink  more  or 
less.  Before  deflecting  the  anterior  flap  its  upper  limit 
should  be  delineated  by  raising  the  loose  peritoneum  on 


Fig.   189. — Demarcating  the  peritoneal  flap. 


the  front  surface  of  the  lower  segment  of  the  uterus  with 
the  finger  (Fig.  189).  If  nothing  but  peritoneum  is  raised 
there  will  be  little  or  no  oozing,  but  this  will  not  be  the 
case  if  the  anterior  flap  be  fashioned  by  cutting,  for  in  that 
case  a  certain  amount  of  subserous  muscle  will  be  included 
in  it.  The  separation  of  the  peritoneum  on  the  front  of 
the  lower  uterine  segment  is  effected  easily,  except  along 
a  frsenum-like  attachment  in  the  middle  line,  which  may 
require  a  touch  with  the  scalpel. 


298 


GYNECOLOGICAL   SURGERY 


The  chief  care  in  dissecting  off  this  flap  is  to  see  that 
the  bladder  is  not  injured  (Fig.  190).  If  the  operator  is 
in  any  doubt  as  to  the  condition  of  this  organ,  he  should 
have  a  sound  passed  into  it,  but  to  the  experienced  eye 
it  is  usually  recognizable  as  a  ridge  running  across  the 
anterior  surface  of  the  peritoneum  at  the  bottom  of  the 
utero-vesical  pouch. 


Fig.  190. — Dissecting  the  anterior  peritoneal  flap. 

viii.  Clamping  the  uterine  vessels. — After  the  anterior 
flap  has  been  separated  and  the  broad  ligaments  have  been 
opened  up,  the  uterine  vessels  can  often  be  seen  running 
up  the  uterine  wall,  or,  if  not  seen,  can  be  felt  pulsating, 
and  at  this  stage  pressure-forceps  are  applied  to  them  on 
each  side  (Fig.  191). 

In  many  cases  the  uterine  vessels  can  be  clamped 
before  reflecting  the  anterior  flap,  a  procedure  which  has 


SUBTOTAL  HYSTERECTOMY 


299 


the  advantage  of  minimizing  any  oozing  during  the  per- 
formance of  the  latter  (Fig.  190). 

ix.  Dissecting  down  the  posterior  flap  of  peritoneum. 
— If  the  full  extent  of  the  movable  peritoneum  on  the 
front  of  the  uterus  has  been  utilized  in  making  the  anterior 
flap,  a  posterior  flap  is  not,  as  a  rule,  necessary.  If,  how- 
ever, it  is  desired  to  make  one,  the  assistant  should  drag 
the  uterus  forwards,  and,  the  upper  limit  of  the  posterior 


Fig.   191. — Clamping  the  uterine  vessels. 

flap  having  been  indicated  with  the  scalpel,  the  peritoneum 
is  deflected  downwards.  As  this  membrane  is  more  adherent 
to  the  posterior  than  to  the  anterior  surface  of  the  uterus, 
greater  difficulty  will  be  found  in  its  separation  than  in  the 
case  of  the  anterior  flap,  and  care  must  be  taken  not  to 
button-hole  it.  Very  often  it  is  impossible  to  limit  the 
flap  to  peritoneum  only,  and  some  of  the  subjacent  tissue 
has  to  be  dissected  off  with  it,  when  oozing — which  is, 
however,  of  little  consequence — may  be  rather  marked. 


3oo 


GYNAECOLOGICAL  SURGERY 


x.  Removing  the  uterus  and  tumour. — The  operator 
now  pulls  the  uterus  over  towards  him  with  his  left  hand, 
and  amputates  it  slightly  above  the  limit  of  the  reflected 
flaps  and  just  above  the  point  where  the  uterine  vessels 
are  clamped  (Fig.  192).  The  stump  of  cervix  that  remains 
will,  if  the  vessels  have  been  properly  occluded,  appear  white. 


Fig.  192. — Amputating  the  uterus. 


The  method  of  amputating  the  uterus  may  be  carried 
out  in  different  ways.  Some  authorities  advocate  a  wedge- 
like incision  so  as  to  form  flaps  of  cervical  tissue,  which, 
when  sutured  together,  obliterate  the  raw  surface  of  the 
stump.  Other  surgeons  aim  at  removing  as  much  as 
possible  of  the  cervical  stump,  short  of  performing  total 
hysterectomy,  in  order  to  extirpate  any  diseased  mucous 
membrane  and  reduce  the  bulk  of  the  stump  to  a  minimum. 


SUBTOTAL  HYSTERECTOMY 


301 


This  they  effect  by  a  circular  movement  of  the  scalpel  while 
strong  traction  is  made  on  the  portion  being  excised.  If 
this  manoeuvre  is  carried  to  its  extreme,  as  practised  by 
Bland-Sutton,  nothing  is  left  after  the  excision  but  a  thin 
shell  of  cervical  tissue.  We  have  practised  both  these 
methods,  but  as  a  rule  we  prefer  to  cut  the  cervix  straight 
across. 

Directly    the    uterus   is    amputated   the    stump   should 


Fig.   193. — Passing  the  ligature  to  secure  the  uterine 
artery. 

be  seized  with  a  volsella  and  drawn  up  for  inspection. 
All  blood-clots  having  been  cleared  away,  and  any  unsecured 
vessel  clamped,  the  ligature  of  the  vessels  is  proceeded 
with. 

xi.  Ligaturing  the  uterine  vessels. — The  cervical  tissue 
on  each  side  is  transfixed  with  a  curved  needle  threaded 
with  No.  4  silk,  in  front  of  the  points  of  the  forceps  which 
are  clamping  the  uterine  vessels  (Fig.  193).  The  ligature 
is  then  tied  below  the  forceps  so  as  to  encircle  the  vessels, 
the   assistant   meanwhile   holding  the   forceps   horizontally 


302 


GYNAECOLOGICAL  SURGERY 


to  prevent  their  points  from  catching  in  the  grip  of  the  liga- 
ture (Fig.  194).  If  when  the  forceps  are  removed  there  is 
oozing  from  the  uterine  vessels,  these  must  be  reclamped 
and  another  ligature  applied.  If  in  spite  of  such  ligatures 
the  stump  is  not  quite  dry,  the  oozing  is  due  to  the  anasto- 
mosis between  the  vessels  of  the  cervix  and  the  vaginal 
arteries.    This  oozing  can  be  stopped  by  one  or  two  mattress- 


Fig.   194. — Securing  the  uterine  artery. 


sutures  passed  through  the  stump.  Additional  ligatures 
may  be  applied  directly  around  the  free  ends  of  the  uterine 
vessels,  and  thus  assurance  be  rendered  doubly  sure. 

xii.  Securing  the  ovarian  vessels  and  round  ligaments. 
— We  shall  describe  four  ways  of  performing  this  step  of 
the  operation  : 

1.  A  needle  armed  with  No.  4  silk  is  passed  through 
that  portion  of  the  broad  ligament  which  is  internal  to 


SUBTOTAL  HYSTERECTOMY 


303 


the  forceps  clamping  the  ovarian  vessels  and  round  liga- 
ment (Fig.  195).  The  ligature  is  then  brought  across  the 
round  ligament  and  outside  the  forceps  over  the  upper 
border  of  the  ovarico-uterine  ligament  so  that  the  ovarian 
vessels  and  round  ligament  are  secured  with  the  same 
ligature  (Fig.  196).  This  is  the  quickest  way  to  secure  these 
structures,  but  it  has  the  obvious  disadvantage  that  if  the 


Fig.  195. — Passing  the  ligature  to  secure  the 
ovarian  artery. 

round  ligament  retracts  from  the  grasp  of  the  ligature  the 
latter  is  of  no  further  use,  and  the  ovarian  vessels  will 
bleed.  This  method  may  be  followed  with  almost  certain 
security  when  the  round  ligaments  and  ovarian  pedicle 
are  very  thin  and  elongated,  but  only  in  such  cases.  The 
operation  is  concluded  by  suturing  the  peritoneal  flaps 
across  the  stump  by  means  of  a  continuous  silk  suture 
from  left  to  right  (Figs.  197,  198). 

2.  In  the  second  method,  a  needle  into  which  is  tied 
a  long  piece  of  No.  4  silk,  doubled  so  that  the  ends  are 


Fig.   197. — Closing  the  perito- 
neum over  the  stump. 


SUBTOTAL  HYSTERECTOMY 


305 


Fig.   198. — First  method  of  treating  the 
pedicles  and  flaps. 


equal,  is  made  to  transfix  that  portion  of  the  broad  liga- 
ment which,  is  internal  to  the  forceps  clamping  the  vessels 
but  external  to  the  round  ligament.  The  ligature  is  now 
divided  so  that 
the  needle  is  left 
attached  to  the 
inner  half  of  it. 
The  outer  half 
of  the  ligature  is 
then  used  to  sur- 
round the  ova- 
rian vessels  and 
Fallopian  tube,  while  the  internal  ligature  by  means  of 
its  attached  needle  is  made  to  re-transfix  both  layers  of 
the  broad  ligament  internally  to  the  round  ligament,  this 
structure  being  pulled  into  its  grip  as  it  is  tied.  The 
advantage  of  this  method,  which  is  the  one  we  have 
generally  employed,  is  that  the  ovarian  vessels  are  ren- 
dered as  secure  as  possible,  and  that  the  mattress-suture 
controlling  the  round  ligament  gathers  up  a  great  deal  of 
the  slack  of  the  broad  ligament  (Fig.  199). 

3.  We  have  devised  another  method,  which  appears 
to  us  an  improve- 
ment on  the  one 
last  described,  be- 
cause in  it  the 
ligature  securing 
the  round  liga- 
ment is  also  used 
to  close  laterally 
the  gap  in  the 
broad  ligament  by  attaching  the  end  of  the  round  liga- 
ment to  the  angle  of  the  stump,  thus  reducing  the  length 
of  the  peritoneal  suture-line  over  the  stump.  This  is 
effected  by  running  the  inner  half  of  the  ligature  along 
the  posterior  layer  of  the  broad  ligament  as  a  pleating 
suture,    the    last    pleat    including   the    peritoneum   on  the 


Fig.   199. — Second  method  of  treating 
the  pedicles  and  flaps. 


306 


GYNECOLOGICAL  SURGERY 


Fig.  200.— Third  method  of  treating 
the  pedicles  and  flaps. 


posterior  surface  of  the  stump.  From  this  surface  of  the 
stump  it  is  carried  across  the  stump  and  made  to  transfix 
the   anterior  peritoneal  flap  well   internally  to  the  round 

ligament,  so  that 
when  tied  the 
broad  ligament  is 
puckered  up  and 
the  round  liga- 
ment pulled  in  to- 
wards the  middle 
line  (Fig.  200). 

4.  The  last  me- 
thod is  identical 
with  the  one  just 
described,  except  that  only  one  ligature  is  used.  The 
ovarian  vessels  and  tube  having  been  secured  as  indicated, 
the  free  end  of  the  ligature  to  which  the  needle  is  attached 
is  made  to  follow  the  same  path  as  that  of  the  inner  ligature 
in  Method  3,  and  is  eventually  tied  to  the  other  free  end 
of  the  ligature  securing  the  ovarian  vessels,  the  round 
ligament  being  pulled  into  its  grip  meanwhile.    This  method 

(Fig.  201)  is  the 
quickest  of  all,  but 
inferior  in  point  of 
security  to  No.  3. 

xiii.  Suturing 
the  broad  liga- 
ments and  perito- 
neal flaps.  —  The 
unclosed  portion 
of  the  peritoneum 
which  intervenes 
between  the  ligatures  that  include  the  round  ligaments 
is  now  to  be  closed.  Where  this  gap  is  considerable,  as 
occurs  in  the  two  methods  first  described  for  securing 
the  ovarian  vessels  and  round  ligament,  closure  should  be 
effected   by   approximating   the    edges   with    a   continuous 


Fig.  201. — Fourth  method  of  treating 
the  pedicles  and  flaps. 


SUBTOTAL  HYSTERECTOMY  307 

No.  2  or  No.  4  silk  suture  on  a  small  curved  needle.  The 
suture  should  be  started  just  internally  to  the  point  where 
the  left  round  ligament  is  tied,  and  should  be  carried  across 
to  a  corresponding  suture  on  the  right  side  (Fig.  197). 

The  result  will  be  neater  if  the  operator  adopts  a  Lem- 
bert's  suture,  particularly  when  passing  the  needle  through 
the  peritoneum  on  the  posterior  surface  of  the  stump. 
This  proceeding  ensures  that  the  suture-line  lies  posteriorly, 
i.e.  facing  the  rectum,  instead  of  along  the  top  of  the 
stump,  where  it  is  much  more  in  danger  of  contracting 
adhesions  to  omentum  and  small  intestine.  It  has  been 
seriously  advised  to  effect,  by  means  of  a  large  posterior 
flap,  a  suture  which  runs  along  the  front  of  the  stump, 
i.e.  along  the  bottom  of  the  utero-vesical  pouch.  This  is 
the  worst  position  for  the  suture-line,  because  no  utero- 
vesical  pouch  exists  after  the  proper  performance  of  a 
subtotal  hysterectomy,  and  the  suture-iine  is  in  the  same 
danger  of  adhesion  as  when  situated  along  the  top  of  the 
stump,  while  the  formation  of  a  large  posterior  flap  prolongs 
the  operation,  causes  more  oozing,  and  is  in  many  cases 
entirely  impracticable.  If  the  third  or  the  fourth  method 
of  securing  the  ovarian  vessels  and  round  ligaments  has 
been  followed,  the  peritoneal  gap  is  closed  by  one  or  two 
mattress-sutures  (Figs.  200,  201).  The  operator  must  bear 
in  mind  the  position  of  the  bladder,  otherwise  it  may  be 
transfixed  when  the  needle  is  passed  through  the  anterior 
flap. 

xiv.  Closing  the  abdominal  cavity. — See  p.  285. 

Difficulties,  i.  Small  incision. — If  the  primary  incision 
is  not  of  sufficient  length,  it  can  easily  be  enlarged  in  an 
upward  direction,  first  placing  a  swab  over  the  bowels 
and  avoiding  the  navel  by  incising  round  it.  If  the  peri- 
toneum cannot  be  further  lengthened  towards  the  pubis 
on  account  of  the  bladder,  it  will  often  be  found  that  the 
division  of  fascia  right  down  to  the  bone  is  of  great 
advantage  in  aiding  the  delivery  of  the  tumour. 

ii/Nature  of  the  tumour. — When  the  uterus  is  enlarged 


3o8  GYNECOLOGICAL   SURGERY 

by  tumours,  usually  myomata,  growing  in  the  supravaginal 
cervix  or  bulging  into  the  broad  ligaments,  it  cannot 
be  delivered  through  the  abdominal  wound,  because  the 
stretched  peritoneum  over  the  lower  uterine  segment  and 
broad  ligaments  fixes  the  organ. 

These  tumours  require  special  treatment  (see  pp.  338 
and  406). 

iii.  Impaction. — The  tumour,  or  part  of  it,  may  be  im- 
pacted in  Douglas's  pouch  and  held  there  by  atmospheric 
pressure.  This  difficulty  may  be  surmounted  by  so  tilting 
the  tumour  that  a  little  air  can  rush  in  under  it,  or  by 
seizing  it  with  the  volsella,  or  by  a  combination  of  the 
two  methods  (Fig.  184). 

iv.  Adhesions. — The  tumour  may  be  held  fast  by 
adhesions,  so  that  it  cannot  be  delivered  until  they  are 
separated.  If  so,  the  adhesions  must  be  separated  with 
great  care  by  means  of  the  fingers,  dissecting  forceps, 
scissors,  scalpel,  or  swab.  If  the  freed  ends  of  the  adhe- 
sions bleed,  they  should  be  carefully  ligatured  with  No.  2 
silk.  Special  care  must  be  taken  in  separating  the  intes- 
tinal adhesions,  because  wounding  the  intestine  may  result 
in  peritonitis  with  death,  or  a  faecal  fistula.  It  will  be  found 
that  intestinal  adhesions  are  often  best  separated  by  a 
stroking  movement  of  the  swab  on  the  tumour  portion 
of  the  adhesions ;  but  if  they  are  so  tough  that  they  will 
not  separate  without  cutting,  and  the  intestine  is  so  close 
that  there  is  a  danger  of  wounding,  it  will  be  safer  rather  to 
cut  off  the  superficial  layer  of  the  uterine  wall  to  which  the 
adhesions  are  attached,  and  leave  it  tethered  to  the  intestine, 
or  deliberately  to  resect  the  involved  portion  of  the  gut.  If 
the  intestine  is  wounded,  it  must  be  repaired  according  to 
the  manner  described  elsewhere.  In  the  case  of  a  firmly 
adherent  portion  of  omentum  it  is  best  to  ligature  and 
divide  it,  afterwards  carefully  examining  the  cut  end  to 
make  sure  that  it  is  not  oozing. 

Dressing — See  p.  44.  The  vagina  is  carefully  cleansed 
with  swabs  on  long  forceps,  by  which  means  any  blood- 


SUBTOTAL  HYSTERECTOMY  309 

clot  that  may  have  escaped  through  the  cervical  canal 
can  be  removed,  or,  if  any  serious  bleeding  is  taking  place 
from  the  stump,  as  rarely  happens,  it  might  be  detected 
and  dealt  with  at  once. 

It  is  a  good  plan  to  empty  the  bladder  with  a  catheter 
before  sending  the  patient  back  to  bed,  so  that  for  some 
hours  she  need  not  be  disturbed.  A  proper  amount  of 
urine  will  be  an  indication  that  the  ureters  are  intact,  and 
the  absence  of  blood  will  show  that  the  urinary  tract  has 
not  been  injured. 

After-treatment. — See  Chapter  xxxn. 

II.  BY  LIGATURE 

The  great  advantage  of  this  method  is  that,  when  pro- 
perly carried  out,  it  is  an  almost  bloodless  procedure.  It 
is  eminently  suitable  for  cases  in  which  the  disease  affects 
the  uterine  body  alone  and  the  latter  is  freely  movable, 
and  in  which  the  patient  is  already  so  exsanguinated  that 
every  drop  of  blood  is  of  vital  importance  to  her.  We 
ourselves  as  a  routine  practice  have  abandoned  this  technique 
for  the  method  just  described,  because  in  cases  of  difficult 
hysterectomy,  especially  where  the  broad  ligaments  are 
shortened,  twisted,  or  otherwise  deformed,  it  is  very  diffi- 
cult to  ligature  the  vessels  securely  prior  to  the  removal 
of  the  tumour,  and  the  pedicles  had  often  to  be  religatured, 
necessitating  the  loss  of  much  time  and  the  use  of  an 
increased  quantity  of  ligature  materials. 

The  method,  in  spite  of  these  defects,  is  in  straight- 
forward cases  an  excellent  one,  and  we  think  that  surgeons 
who  are  not  used  to  this  class  of  work  will  find  it  the  most 
satisfactory  to  begin  with. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation. — The  steps  of  the  operation  are  the  follow- 
ing :— 

i.  Opening  the  abdominal  cavity- — See  p.  276. 

ii.  Inserting  the  large  swab. — See  p.  293. 


3io 


GYNECOLOGICAL  SURGERY 


iii.  Securing  the  ovarian  vessels. — The  operator  pulls 
the  uterus  over  to  his  side  so  that  the  broad  ligament  on 
the  assistant's  side  is  put  upon  the  stretch.  The  surgeon, 
with  a  pedicle-needle  threaded  double  with  No.  4  silk, 
passes  the  ligature  through  the  top  of  the  broad  ligament 
just  below  the  ovarian  vessels.     The  loop  of  silk  is  then 


Fig.  202. — Subtotal  hysterectomy  by  ligature  method  : 
Passing  the  ovarian  ligature. 


pulled  free  of  the  eye  of  the  pedicle-needle  (Fig.  202)  and 
is  divided  with  scissors.  Both  ends  are  now  freed  of  the 
needle,  which  is  withdrawn,  leaving  two  ligatures  trans- 
fixing the  broad  ligament.  Having,  by  pulling  on  the 
two  ligatures,  found  the  ends  belonging  to  each,  the  operator 
takes  the  ligature  nearest  the  ovary  and  by  a  sawing  move- 
ment separates  it  from  the  other  ligature,  and  then  ties 
it  close  to  the  ovary  (Fig.  203).     He  ties  the  other  liga- 


SUBTOTAL  HYSTERECTOMY 


311 


ture  in  a  similar  manner,  only  in  this  case  draws  it  in 
towards  the  uterus  and  ties  it  as  near  that  organ  as  pos- 
sible. Thus  there  is  a  free  space  left  between  the  tube 
and  ovarian  vessels  and  that  portion  of  the  broad  liga- 
ment which  lies  below  them.  If  the  ovary  is  going  to 
be  taken  away,  the  ovarico-pelvic  ligament  is  tied  off  in 
the  same  way.  That  portion  of  the  broad  ligament  which 
has  been  ligatured  is  now  divided  with  scissors  between 
the  ligatures  as  shown  in  Fig.  204.     The  opposite  side  is 


Fig.  203. — Separating  the 
ligatures. 


next  treated  in  a  similar  manner  by  some  surgeons  ;  others 
prefer  to  finish  off  one  side  first  according  to  the  succeeding 
sections.  It  is  purely  a  matter  of  taste  and  convenience 
which  method  is  followed,  although  perhaps  less  blood 
is  lost  if  the  two  ovarian  vessels  are  tied  off  on  each  side 
before  proceeding  to  secure  the  uterine  artery. 

iv.  Securing  the  round  ligament. — If  the  round  liga- 
ment is  near  the  Fallopian  tube,  it  may  be  secured  by 
the  same  ligature  which  surrounds  the  ovarian  end  of  the 
ovarian  vessels.  If  on  account  of  the  tumour  the  round 
ligament  is  much  displaced,  or  if  it  is  hypertrophied,  then 
it  should  be  separately  secured  by  passing  beneath  it  a 


312 


GYNECOLOGICAL  SURGERY 


double  ligature  of  No.  4  silk  (Fig.  205),  drawing  the  ligatures 
apart  and  tying  it  off  in  two  places,  and  dividing  it  between 
the  ligatures  (Fig.  206).  It  is  better  to  tie  the  round  liga- 
ment separately  under  the  conditions  detailed,  because, 
having  a  tendency  to  contract,  it  may  escape  from  a  ligature 
holding  it,  and  set  free  the  ovarian  vessels. 

v.  Opening  up  the  broad  ligaments. — See  p.  296. 

vi.  Securing  the  uterine  vessels The   uterine    artery 

having  been  brought  into  view  or  its  position  ascertained 


Fig.  204. — Dividing  the  ovarian  pedicle. 


by  palpation,  the  operator  pulls  the  uterus  upwards  and 
towards  his  side,  and  then  passes  a  rectangular  curved 
needle  between  the  uterus  and  the  uterine  vessels,  being 
careful  not  to  prick  them  in  so  doing  (Fig.  207).  The 
uterine  vessels  are  tied  (Fig.  208).  The  assistant  then  pulls 
the  uterus  over  towards  his  side,  so  that  the  uterine  vessels 
may  be  secured  in  a  similar  manner  on  the  opposite  side, 
vii.  Dissecting  down  the  anterior  flap  of  peritoneum. — 
See  p.  296  and  Fig.  209. 


SUBTOTAL  HYSTERECTOMY  313 


Fig.  205. — Passing  the  round-ligament  ligature. 


Fig.  206. — Securing  the  round  ligament. 


3i4 


GYNECOLOGICAL  SURGERY 


viii.  Dissecting  down  the  posterior  flap  of  peritoneum. — 
See  p.  299  and  Fig.  210. 

ix.  Removing  the  uterus  and  tumour. — See  p.  300  and 
Fig.  192. 

x.  Suturing  the  peritoneal  flaps. — The  ovarian  vessels 
and  round  ligaments  being  already  ligatured,  and  all  oozing 
from  the  stump  having  been  stopped,  the  peritoneal  flaps 


Fig.  207. — -Passing  the  ligature 
round  the  uterine  artery. 


are  united  from  left  to  right  by  a  continuous  No.  2  silk 
suture  (Fig.  197). 

xi.  Closing  the  abdominal  cavity. — See  p.  285. 

Dressing  and  after-treatment. —  See  p.  44  and  Chapter 

XXXII. 

Difficulties  in  subtotal  hysterectomy  for  disease  of  the 
body  of  the  uterus. — The  difficulties  of  this  operation 
vary  immensely  in  different  cases.  They  are  least 
when  the  patient  has  had  children,  the  pelvis  is  shallow, 
the  abdominal  wall  thin,  the  enlargement  considerable 
and  limited  to  the  upper  part  of  the  body  of  the  uterus, 


Fig.  208. — Securing  the  uterine  artery. 


Fig.  209. — Dissecting  the  anterior  flap. 


3i6 


GYNECOLOGICAL  SURGERY 


and  the  broad  ligaments  and  cervix  elongated  and  thin. 
Where  the  opposite  obtains,  the  difficulties  may  be  con- 
siderable, and  especially  so  where  the  tumour  has  invaded 
the  lower  segment  of  the  uterus  and  produced  much  thick- 
ening of  the  cervix.  The  gravest  difficulties  are,  however, 
incurred  by  the  operator  mistakenly  employing  the  tech- 


Fig.  210. — Dissecting  the 
posterior  flap. 

nique  just  described  to  cases  of  cervical  or  broad-ligament 
myomata. 

HYSTERECTOMY   WITH   SALPINGO- 
OOPHORECTOMY 

In  the  description  already  given  of  hysterectomy,  it  has 
been  taken  for  granted  that  the  ovaries  and  tubes  were 
healthy,  and  they  have  accordingly  been  conserved. 

It  not  infrequently  happens,  however,  that  one  or 
both  appendages  are  the  seat  of  disease  which  may  be  of 
a  chronic  inflammatory  nature,  with  or  without  dilatation 


SUBTOTAL  HYSTERECTOMY 


317 


Fig    211. — Hysterectomy  and  salpingo-obphorectomy 
Pulling  up  the  appendage. 


Fig.  212. — Dividing  the  ovarico-pelvic  ligament  and 
round  ligament. 


3i8  GYNECOLOGICAL  SURGERY 

of  the  tube  (pyosalpinx  or  hydrosalpinx).  In  such  circum- 
stances, the  appendages  may  have  to  be  removed  with 
the  uterus. 

Separation  of  the  appendage — The  diseased  appen- 
dage is  pulled  up  and  separated  from  any  adjacent 
structures  to  which  it  is  adherent.  The  precise  method  of 
doing  this  and   the   difficulties  encountered  are   described 


Fig.  213. — Securing  the  uterine  artery. 

elsewhere.  The  appendage  having  been  freed,  the  ovarico- 
pelvic  ligament  is  clamped  with  pressure-forceps  externally 
to  the  Fallopian  tube  and  ovary  (Fig.  211).  A  further  pair 
of  forceps  having  been  applied  an  inch  nearer  the  uterus,  the 
ligament  is  divided  between  the  two  (Fig.  212).  The  round 
ligament  separately  clamped  is  then  divided.  The  broad 
ligament  being  thus  opened  up,  the  uterine  artery  is  exposed 
and  clamped  (Fig.  213),  and  the  operator  then  proceeds  on 
the  lines  indicated  on  pp.  298-307. 


CHAPTER    XV 
ABDOMINAL   TOTAL    HYSTERECTOMY 

I.    BY   THE   ROUTINE   METHOD 

This  operation  may  be  indicated  when  the  uterus  is  the 
seat  of  myomata,  of  malignant  disease,  or  of  fibrosis,  and 
further  under  occasional  conditions  of  sepsis,  of  injury,  of 
congenital  deformity,  and  in  certain  cases  of  inflammatory 
disease  of  the  uterine  appendages. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments.  —  See  general  list,  p.  276.  In  addition 
Fenton's  dilator  No.  16  will  be  required. 

Operation. — i.  Directly  the  patient  is  put  into  the 
Trendelenburg  position  an  assistant  should  place  the  largest 
size  Fenton's  dilator  in  the  vagina,  so  that  if  the  operator 
elects  first  to  cut  into  the  vaginal  canal  posteriorly,  this 
wall  can  be  clearly  defined  and  steadied  by  the  pressure 
of  the  instrument. 

ii.  Opening  the  abdominal  cavity. — See  p.   276. 

iii.  Inserting  the  large  swab. — See  p.  293. 

iv.  Clamping  the  ovarian  vessels  and  round  ligaments. 
— The  ovarian  vessels  and  round  ligaments  are  clamped 
with  pressure-forceps  on  each  side,  as  described  at  pp. 
293-96  (Fig.  214). 

v.  Dividing  the  broad  and  round  ligaments.  —  See  pp. 
293-96. 

vi.  Reflecting  the  bladder. — An  incision  is  made  through 
the  peritoneum  on  the  front  of  the  uterus,  joining  the 
incision  in  either  broad  ligament,  in  the  manner  described 
at  p.  296,  and  the  anterior  peritoneal  flap  and  subsequently 
the  bladder  are  then  carefully  rolled  back  by  pressure  ap- 
plied with  a  swab  until  the  vaginal  wall  is  reached.     This 

319 


320 


GYNECOLOGICAL  SURGERY 


Fig.  214. — Routine  abdominal  total  hysterectomy 
Dividing  the  top  of  the  broad  ligament. 


Fig.  215,—  Reflecting  the  bladder, 


ABDOMINAL  TOTAL  HYSTERECTOMY    321 

is  identified  by  feeling  the  limit  of  the  vaginal  cervix  and 
recognizing  the  parallel  muscle-fibres  of  the  vagina  (Fig.  215). 
vii.  Cutting  through  the  posterior  vaginal  wall. — The 
uterus  is  now  dragged  well  forward  with  a  volsella,  and 
an  incision  made  with  scissors  into  the  vagina  through  the 
posterior  vaginal  wall  (Fig.  216).  The  position  of  this 
structure  is  first  rendered  accessible  by  the  assistant  thrust- 
ing the  point  of  the  dilator  well  up  the  vagina.     In  per- 


Fig.  216. — Cutting  through  the  posterior  vaginal  wall. 


forming  this  he  should  seize  the  outer  end  of  the  dilator 
through  the  sterile  sheet  that  covers  the  thighs  of  the  patient. 
viii.  Cutting  through  the  anterior  vaginal  wall. — The 
first  and  second  fingers  of  the  left  hand  are  pushed  through 
the  posterior  opening  into  the  vagina,  and  the  anterior 
vaginal  wall  is  stretched  over  them  ;  then  with  the  scalpel 
in  his  right  hand  the  surgeon  cuts  through  the  anterior 
vaginal  wall  on  to  his  fingers  (Fig,  217)  which  are 
slipped  through  the  opening  as  it  is  enlarged, 
v 


322 


GYNAECOLOGICAL  SURGERY 


ix.  Clamping  the  uterine  vessels  and  removing  the 
uterus. — The  uterus  is  now  only  held  by  a  couple  of  lateral 
folds,  each  of  them  consisting  of  a  leash  of  uterine  vessels, 
some  cellular  tissue  surrounding  them,  the  lateral  cervico- 
pelvic  ligament  and  utero-sacral  ligament,  and  the  wall 
of  the  lateral  vaginal  fornix. 

The  uterus  being  well  pulled  up,  a  pair  of  long  pressure- 


Fig.  217. — Gutting  through  the  anterior  vaginal  wall. 


forceps  is  applied  on  each  side  to  these  folds,  which  are 
then  divided  with  scissors  close  to  the  cervix,  and  the 
organ  is  removed  (Fig.  218). 

x.  Ligature  of  the  uterine  vessels  and  lateral  vaginal 
vessels. — In  some  cases  these  can  be  secured  together  by  a 
ligature  passed  through  the  lateral  angles  of  the  vagina, 
and  tied  over  the  uterine  artery  proximally  to  the  forceps. 
In  other  cases,  where  the  mass  of  tissue  held  in  the  grip 


ABDOMINAL  TOTAL  HYSTERECTOMY     323 

of  the  forceps  is  large,  it  is  better  to  transfix  the  mass 
under  the  uterine  artery  with  a  needle  into  which  a  double 
ligature  has  been  tied.  The  ligature  having  been  cut, 
one  half  is  tied  over  the  uterine  artery,  and  the  other  half, 
to  which  the  needle  is  attached,  is  used  to  mattress  the 
lateral  vaginal  angle  (Figs.  219  and  220). 

xi.  Ligature  of  the  ovarian  vessels. — See  pp.  302-06. 

xii.  Suture  of  the  broad  ligaments  and  peritoneal  flaps. 
— Any  of  the  methods  described  on  p.  302  may  be  used  to 


Fig.  218. — Clamping  the  uterine  vessels. 


close  the  peritoneum  over  the  operation  area.  The  vagina 
should  be  left  wide  open  for  drainage  (Fig.  221).  Its  total 
closure  by  suture  is  fraught  with  danger. 

xiii.  Closing  the  abdominal  cavity. — See  p.  285. 

Difficulties  and  dangers. — When  the  vagina  is  being 
opened,  care  must  be  taken  not  to  injure  the  rectum,  and 
also  not  to  cut  into  the  plane  of  cellular  tissue  between 
the  rectum  and  the  vagina.  In  the  latter  case  difficulty 
will  be  found  in  opening  the  vagina,  and  a  large  oozing 


324 


GYNECOLOGICAL  SURGERY 


area  will  be  opened  up.     These  difficulties  are  overcome  by 
the  use  of  the  dilator  described. 


Fig.  219. — Ligature  of  the  uterine  artery. 

Besides  the  danger  of  wounding  the  rectum  and  bladder, 
the  ureters  may  be  ligatured  or  cut  when  the  uterine  vessels 


Fig.  220. — Mattressing  the  lateral  vaginal  angle. 


ABDOMINAL  TOTAL  HYSTERECTOMY    325 

are  secured,  so  that  the  lateral  folds  should  be  divided  as 
near  the  cervix  as  possible. 

The  operation  in  thin  patients  with  a  uterus  merely 
enlarged  but  not  deformed  presents  no  special  difficulties, 
but  it  is  otherwise  in  a  stout  woman  with  a  small  uterus 
and  a  deep  pelvis.  Here,  from  the  depth  at  which  the 
operator  is  working,  the  embarrassment  of  flatus-laden 
intestines,  and  the  presence  of  much  adipose  tissue,  the 
resources  of  the  surgeon  may  be  greatly  taxed. 


Fig.  221. — Closing  the  peritoneum  over  the  open 
vagina . 

Dressing  and  after-treatment. — See  p.  44   and  Chapter 

XXXII. 

A  certain  number  of  cases  present  some  foul  discharge 
and  a  little  fever  during  the  second  week,  due  to  infection 
of  the  operation  area  from  the  vagina.  Vaginal  douches 
should  be  given  after  the  first  week. 

Alternative  technique. — In  some  cases  it  is  better  to 
open  the  anterior  vaginal  fornix  first,  and  to  push  the  fingers 
through  on  to  the  posterior  vaginal  wall,  which  is  then 
divided  on  to  them  from  behind ;  or  the  posterior  vaginal 


326  GYNECOLOGICAL  SURGERY 

wall  may  be  divided  through  the  opening  in  the  anterior. 
This  is  facilitated  by  seizing  the  vaginal  cervix  with  a  vol- 
sella  and  drawing  it  out  through  the  anterior  opening  in 
the  manner  described  on  p.  333.  In  easy  cases  a  rapid 
method  of  removing  the  uterus  is  to  transfix  both  anterior 
and  posterior  vaginal  walls  with  the  scalpel  from  the  front, 
and  then  to  cut  upwards  and  outwards  on  either  side, 
having  previously  clamped  the  uterine  arteries  just  before 
they  enter  the  uterus.  Care  must  be  taken  not  to  injure 
the  rectum  with  the  point  of  the  scalpel  in  doing  this. 

II.  BY   DOYEN'S    METHOD 

This  method  of  performing  total  hysterectomy  is  advo- 
cated and  practised  by  certain  operators.  We  have  per- 
formed it,  but  consider  it  inferior  to  the  usual  method, 
described  at  pp.  319-26.  The  technique  may  have  to 
be  modified  in  different  cases.  It  is  often  impossible  to 
rotate  the  uterus  sufficiently  far  forwards  to  get  at  the 
cervix  until  the  upper  parts  of  the  broad  ligaments  are  first 
divided.  The  method  is  an  easy  one  in  simple  cases,  but 
when  dealing  with  cervical  tumours  it  is  impossible  to 
carry  it  out. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list  (p.  276).  Fenton's 
dilator  No.  16  will  also  be  required. 

Operation.  i.  Opening  the  abdominal  cavity. — See 
p.  276. 

ii.  Insertion  of  large  swab. — See  p.  293. 

iii.  Opening  the  vagina  posteriorly. — The  fundus  is 
seized  with  a  volsella,  the  uterus  is  drawn  upwards  and 
forwards,  and  the  edge  of  the  cervix  is  felt  as  it  impinges 
against  the  anterior  boundary  of  Douglas's  pouch.  A  longi- 
tudinal incision  of  about  an  inch  is  now  made  in  the 
middle  line  upon  the  cervix,  and  the  vagina  opened 
posteriorly  (Fig.  222).  This  proceeding  is  facilitated  by 
placing  the  large  Fenton's  dilator  in  the  vagina  previously 
{see  p.  319). 


DOYEN'S  HYSTERECTOMY  327 

iv.  Seizing  the  cervix. — The  index-finger  of  the  left 
hand  is  introduced  into  the  vagina  through  the  incision, 
and  the  external  os  having  thus  been  located,  another 
volsella  is  guided  to  the  cervix,  which  is  seized  and  its 
vaginal  portion  drawn  through  the  opening  in  the  pos- 
terior vaginal  wall  into  Douglas's  pouch,  any  secretion  that 
is  adhering  to  its  surface  being  swabbed  off. 


Fig.  222. — Doyen's  panhysterectomy  :    Opening  the 
vagina  posteriorly. 

v.  Circular  incision  of  the  vagina  at  the  cervico- 
vaginal  junction. — After  the  cervix  is  pulled  through,  it 
is  held  with  the  left  hand  while  the  surgeon,  with  a  scalpel 
in  his  right  hand,  by  means  of  a  circular  cut  incises  the 
vault  of  the  vagina  at  its  junction  with  the  cervix  (Fig.  223). 
Any  free  oozing  at  this  stage  can  be  controlled  by  pressure- 
forceps. 

vi.  Opening  the  utero  -  vesical  pouch. — The  first  and 
second  fingers   of  the  left  hand  are   now  passed  into  the 


32t 


GYNECOLOGICAL  SURGERY 


vagina  through  the  wound  in  Douglas's  pouch,  and,  working 
through  the  anterior  part  of  the  circular  incision  round  the 
cervix,  proceed  to  separate  the  bladder  from  the  anterior 
surface  of  the  uterus.  This  manoeuvre  may  be  assisted 
with  cuts  of  the  scissors  and  by  the  assistant  strongly 
pulling  the  cervix  upwards  and  forwards  (Fig.  224).  The 
uterus  is  now  pulled  back,  the  fingers  of  the  left  hand  distend 


Fig.  223. — Delivering  and  circumcising  the  cervix. 


the  peritoneum  at  its  reflection  from  the  anterior  surface 
of  the  uterus,  and  an  incision  is  made  on  to  the  fingers 
through  the  peritoneum,  so  that  the  utero-vesical  pouch 
is  opened  into  the  vagina  (Fig.  225). 

vii.  Clamping  and  dividing  the  broad  ligaments. — 
While  the  assistant  pulls  the  uterus  over  to  one  side,  the 
broad  ligament  near  the  cornu  of  the  uterus  on  the  other 
side  is  clamped  and  the  ovarian  vessels  and  round  ligament 
are  thus  secured.  The  surgeon  passes  through  the  posterior 
opening  in  the  vagina  the  first  and  second  fingers  of  his 


DOYEN'S  HYSTERECTOMY 


329 


Fig.  225. — Opening  the  utero-vesical  pouch. 


330 


GYNECOLOGICAL  SURGERY 


Fig.  226. — Dividing  the  base  of  the  right  broad 
ligament. 


Fig.  227. — Removal  of  the  uterus. 


BONNEY'S  HYSTERECTOMY  331 

left  hand  in  front  of  the  undivided  portion  of  the  broad 
ligament,  while  the  thumb  makes  counter-pressure  from 
behind,  thus  controlling  the  uterine  artery.  The  remainder 
of  the  broad  ligament  is  now  divided  with  scissors,  the 
uterine  artery  being  clamped.  The  opposite  side  is  treated 
similarly  and  the  uterus  removed  (Figs.  226  and  227). 

viii.  Ligaturing  the  vessels. — The  ovarian  and  uterine 
vessels  are  ligated  in  the  usual  way  (see  pp.  301-06). 

ix.  Suturing  the  broad  ligaments. — See  p.  306. 

x.  Closing  the  abdominal  cavity. — See  p.  285. 

Dangers. — See  p.  323. 

Dressing  and  after-treatment. — See   p.  44  and  Chapter 

XXXII. 

III.  BY    BONNEY'S    METHOD 

This  operation,  which  may  shortly  be  described  as  a 
reversed  Doyen,  was  planned  by  one  of  us  when  dealing 
with  a  myoma  of  the  posterior  wall  of  the  supravaginal 
cervix  which  had  burrowed  underneath  the  peritoneal 
lining  of  Douglas's  pouch,  and  which  was  so  large  that  it 
had  stripped  the  peritoneum  off  the  rectum  and  had  invaded 
the  mesocolon,  so  that  at  the  first  glance  the  large  intestine 
seemed  to  be  adherent  to  the  fundus  of  the  uterus  and  the 
ordinary  relations  could  not  be  identified.  The  same 
operation  would  serve  in  a  case  where  the  intestines  had 
become  so  adherent  to  the  fundus  of  the  uterus  that  they 
could  not  be  separated  from  above. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity- — See  p. 
276. 

ii.  Clamping  the  round  ligaments.— The  round  liga- 
ments on  each  side  are  clamped  with  pressure-forceps  and 
divided  close  to  their  uterine  attachment. 

Hi.  Stripping  back  the  bladder. — An  incision  is  made 
through  the  peritoneum  across  the  anterior  surface  of  the 
uterus  from  round  ligament  to  round  ligament  (Fig.  228), 


332 


GYNAECOLOGICAL  SURGERY 


after  which  the  peritoneum  is  stripped  back,  together  with 
the  bladder,  by  swab  pressure  (Fig.  229). 


Fig.  228. — Bonney's  hysterectomy  :    Incising  the  peritoneum 
over  the  front  of  the  tumour. 

iv.  Incising  the  anterior  vaginal  wall. — The  bladder 
being  kept  out  of  the  way,  the  anterior  vaginal  wall  is 
divided  with  a  scalpel  or  scissors  (Fig.  230). 


Fig.  229. — Separating  the  bladder. 


BONNEY'S  HYSTERECTOMY  333 

v.  Delivering  the  cervix  through  the  incision  in  the 
anterior  vaginal  wall. — A  pair  of  volsella  forceps  is  passed 
through  the  opening  in  the  anterior  vaginal  wall,  and  the 
cervix  seized  with  them  and  drawn  upwards  and  through 
the  opening,  after  which  the  rest  of  the  mucous  membrane 
of  the  vaginal  vault  at  its  junction  with  the  cervix  is 
circumcised  (Fig.  231). 

vi.  Clamping    and    dividing   the    uterine    arteries. — The 


Fig.  230. — Incising  the  anterior  vaginal  wall. 

surgeon  pulls  the  cervix  well  up  and  divides  the  base  of 
the  broad  ligament  in  the  neighbourhood  of  the  cervix, 
together  with  the  uterine  artery,  which  is  clamped  as  it 
comes  into  view  (Fig.  232),  first  on  one  side  and  then  on 
the  other. 

vii.  Separating  the  tumour  from  the  rectum.  —  After 
the  bases  of  the  broad  ligaments  have  been  divided, 
the  surgeon  is  able  to  pull  the  lower  pole  of  the  uterus 
upwards  to  a  much  greater  extent,  and  the  myoma  on  the 


Fig.  231. — Delivering  the  cervix. 


Fig.  232. — Clamping  the  base 
of  the  broad  ligament. 


BONNEY'S  HYSTERECTOMY 


335 


posterior  wall  is  gradually  separated  from  the  rectum 
with  the  fingers  and  a  few  judicious  cuts  of  the  scalpel 
(Fig.  233). 

viii.  Clamping  the  ovarian  arteries. — The  uterus  as  it 
is  pulled  upwards  is  dragged  well  over  to  one  side,  and 
the   ovarian    artery  of   the    opposite    side,    together    with 


Fig.  233. — Separating  the  uterus  from  the  rectum. 

the  upper  border  of  the  broad  ligament,  comes  into 
view  and  is  clamped  with  pressure-forceps  and  divided 
(Fig.  234). 

ix.  Separating  the  fundus  of  the  uterus. — The  fundus 
of  the  uterus,  which  is  attached  to  the  intestines  by  the 
posterior  layer  of  peritoneum  of  Douglas's  pouch  that 
has  been  pushed  up  by  the  tumour,  is  freed  by  dividing 
this   peritoneum   close   to   the   uterus   across   to  the  other 


336  GYNECOLOGICAL  SURGERY 


Fig.  234. — Clamping  the  left  ovarian  vessels. 


Fig.  235. — Separating  the  fundus  of  the  uterus. 


BONNEY'S  HYSTERECTOMY  337 

side  when  the  opposite  ovarian  vessels  are  clamped  and 
divided,  and  the  uterus  is  free  (Fig.  235).  # 

x.  Ligaturing  the  uterine  arteries  and  lateral  vaginal 
angles. — See  p.  322. 

xi.  Ligaturing  the  ovarian  arteries  and  the  round  liga- 
ments, and  suturing  the  broad  ligaments  and  the  cut  edges 
of  the  peritoneum. — See  pp.  302-07.  As  a  very  large  area 
of  denudation  is  necessarily  left  after  removal  of  the 
uterus  such  as  has  been  described,  as  much  peritoneum 
as  possible  should  be  saved  on  its  anterior  surface.  This 
large  anterior  flap  is  sutured  directly  to  the  cut  peritoneal 
edge  on  the  anterior  surface  of  the  large  intestine. 

xii.  Closing  the  abdominal  cavity- — See  p.  285. 

Dangers. — See  p.  323. 

Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 


w 


CHAPTER    XVI 

HYSTERECTOMY   FOR   CERVICAL   MYOMA 

General  remarks. — A  myoma  growing  from  the  supra- 
vaginal cervix  is  not  suitably  treated  by  the  classical 
methods  of  performing  subtotal  and  total  hysterectomy, 
the  former  because  the  amputation  would  have  to  take 
place  across  the  tumour,  leaving  one-half  of  it  behind,  and 
the  latter  because  in  a  large  cervical  myoma  the  tumour 
is  so  impacted  in  the  pelvis  and  so  overhangs  the  vagina 
that  the  wall  of  this  canal  cannot  be  reached  until  the 
tumour  is  much  displaced  or  actually  cut  away.  In  order 
to  understand  the  technique  of  the  removal  of  these  tumours 
an  appreciation  of  their  anatomical  relations  is  necessary. 
Cervical  myomata  may  be  classified  as — 

(i)  Anterior,  when  a  tumour  springing  from  the 
superficial  muscle  bulges  forwards  and  undermines  the 
bladder. 

(2)  Posterior,  when  a  tumour  similarly  situated  on  the 
posterior  surface  of  the  cervix  either  flattens  the  pouch 
of  Douglas  from  before  backwards  and  compresses  the 
rectum  against  the  sacrum,  or  the  rarer  form  where  the 
tumour  undermines  the  peritoneum  at  the  bottom  of 
Douglas's  pouch,  and,  obliterating  this  cul-de-sac,  lifts 
the  serous  membrane  off  the  anterior  surface  of  the  rectum 
and  sacrum. 

(3)  Lateral,  when  the  myoma,  starting  on  the  side  of  the 
cervix,  burrows  out  into  the  broad  ligament  and  expands 
it.  These  tumours  in  their  growth  outwards  may  fill  the 
whole  broad  ligament  and  sometimes  find  their  way  between 
the  layers  of  the  mesocolon,  the  bowel  lying  sessile  upon 
them.     Their  relation  to   the  ureter  is  important.     Most 

338 


Plate  IV.— Central  Cervical  Myoma. 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    339 

commonly  this  structure  is  underneath  the  growth  and 
to  the  outer  side.  Very  rarely  when  the  myoma  starts 
quite  low  down  at  the  junction  with  the  vagina  it  may 
insinuate  itself  under  the  ureter  and  lift  it  on  its  upper 
surface  high  up  out  of  the  pelvis. 

(4)  Central,  when  the  tumour,  either  of  interstitial 
or  of  submucous  origin,  expands  the  cervix  equally  in 
all  directions.  This  variety  of  tumour  may  present  all 
the  anatomical  vagaries  mentioned  in  connexion  with  the 
other  three  varieties. 

A  cervical  myoma  can  at  once  be  recognized  on  opening 
the  abdominal  cavity  by  noticing  that  the  cavity  of  the 
pelvis  is  more  or  less  filled  by  a  tumour,  elevated  on 
which  is  the  body  of  the  uterus,  like  "  the  lantern  on  the 
dome  of  St.  Paul's  " — to  use  Bland-Sutton's  very  apposite 
simile.  This  characteristic  appearance  does  not  occur 
when  there  is  a  second  tumour  in  the  body  of  the  uterus 
itself ;  and  there  is  a  variety  of  fundal  submucous  myoma 
which,  growing  along  the  cavity  of  the  uterus,  expands 
the  supravaginal  cervix  without  having  any  attachment 
to  it.  This  variety  may  be  termed  the  pseudo-cervical 
myoma. 

(5)  Lastly,  cervical  tumours  may  be  multiple,  so  that 
a  lateral  myoma,  may  be  present  on  both  sides,  or  an  ante- 
rior myoma  may  be  coexistent  with  a  posterior  tumour, 
or  a  lateral  myoma  may  complicate  either  an  anterior  or 
a    posterior  one. 

The  operation  for  the  removal  of  a  cervical  myoma  is 
usually  difficult,  and  may  at  times  be  an  extremely  for- 
midable undertaking.  The  natural  difficulties  of  the  ope- 
ration are,  however,  greatly  enhanced  by  a  want  of 
knowledge  of  the  technique  most  suitable  to  the  occa- 
sion, and  ignorance  on  the  operator's  part  of  the  altered 
anatomical  relations  of  the  surrounding  structures.  It  is 
for  this  reason  that  we  have  laid  such  stress  upon  the 
disturbance  of  the  normal  relations  to  one  another  of 
the  various   structures  involved. 


340  GYNAECOLOGICAL  SURGERY 

I.  HYSTERECTOMY  FOR  A  CENTRAL  CERVICAL 
MYOMA,  WITH  PARTIAL  ENUCLEATION  OF 
THE    BASE 

Preparation  of  the  patient. — See  pp.  82-86. 
Instruments. — See  general  list,  p.  276. 
Operation. — The  steps  of  the  operation  are  as  follows  : — 
i.  Opening  the  abdominal  cavity. — See  p.  276. 


Fig.  236. — Hysterectomy  for  a  central  cervical  myoma  : 
Dividing  the  top  of  the  broad  ligament. 

ii.  Inserting  a  large  swab. — See  p.  293. 

hi.  Clamping  and  dividing  the  ovarian  vessels  and 
round  ligaments. — The  upper  part  of  the  broad  ligament 
containing  the  ovarian  artery  and  ligament  is  preferably 
clamped  and  divided  in  the  usual  way  on  each  side  (pp.  293- 
96,  and  Fig.  236).  In  many  of  these  cases,  however,  the 
uterine  vessels  are  so  elevated  on  the  surface  of  the  tumour 


HYSTERECTOMY  FOR  CERVICAL  MYOMA   341 

that  they  run  almost  parallel  with  the  ovarian  vessels, 
the  result  being  a  formidable  vascular  leash  converging 
towards  the  cornu  on  each  side.  In  such  circumstances 
the  separate  clamping  of  the  ovarian  contingent  is  almost 
impossible,  and  the  whole  mass  must  be  seized  and  divided. 
From  the  many  vessels  thus  opened  up  very  brisk  haemor- 
rhage may  occur,  which  must  be  immediately  controlled  by 
the  application  of  several  pressure-forceps. 


Fig.  237. — Stripping  the  peritoneum  off  the  front  of 
the  tumour. 


The  clamping  of  the  uterine  vessels  is  merely  tem- 
porary, as  these  vessels  will  presently  be  divided  again 
lower  down. 

In  some  cases  the  ovarian  vessels  can  be  isolated  by 
first  dividing  the  round  ligament  and  then  inserting  the 
finger  through  the  hole  in  the  peritoneum  undermining 
them  and  lifting  them  up,  when  they  are  easily  secured. 

iv.  Dissecting  down  the  anterior  flap  of    peritoneum. — 


342  GYNAECOLOGICAL  SURGERY 

An  incision  is  made  between  the  points  where  the  round 
ligaments  have  been  divided  through  the  upper  limit  of 
the  loose  peritoneum  in  front  of  the  uterus  and  well  above 
the  level  of  the  bladder  reflection  (Fig.  237),  and  the  bladder 
is  then  separated,  together  with  the  anterior  flap  of  peri- 
toneum, from  the  surface  of  the  expanded  supravaginal 
cervix  (Fig.  238).     Special  care  must  be  taken  to  see  that 


Fig.  238.— Pushing  back  the  bladder. 

the  bladder  is  not  injured,  as  it  will  probably  be  very  much 
displaced  upwards. 

v.  Incising  the  capsule  of  the  tumour. — The  capsule 
of  the  tumour  formed  by  the  tissues  of  the  expanded 
supravaginal  cervix  is  next  incised  anteriorly  with  a  scalpel 
for  about  2  inches.  The  index-finger  of  the  right  hand 
is  inserted  in  the  incision  and  the  exact  plane  of  separation 
between  the  tumour  and  its  capsule  is  defined  (Fig.  239). 
The  incision  is  now  extended  across  the  supravaginal 
cervix  (Fig.  240). 

If  the  operator  is  in  any  doubt  as  to  the  position  of 
the  bladder,  he  should  have  a  sound  passed  into  this  organ, 
since  it  is  when  incising  the  capsule  of  the  tumour  that 
the  bladder  is  most  often  injured. 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    343 


vi.   Partial  enucleation  of  the   tumour   and   amputation 
of  the  uterus. — A  volsella  is  fixed  in  the  anterior  surface 


Fig.  239.— Exploring  the 
capsule  of  the  tumour. 

of   the   tumour  now  exposed   through  the   incision   in   its 
capsule,  and  it  is  then  pulled  upwards  as  much  as  possible 


Fig.  240. — Enlarging  the  opening 
in  the  capsule  of  the  tumour. 


344 


GYNECOLOGICAL  SURGERY 


whilst  the  operator  continues  the  enucleation  by  passing 
the  fingers  of  the  right  hand  between  the  tumour  and  its 
bed  (Fig.  241).  The  circular  incision  in  the  capsule  is 
extended  by  successive  cuts  towards  the  left,  and  in  the 
course  of  this  proceeding  the  uterine  vessels  on  the  assist- 
ant's side  are  divided  and  immediately  clamped  (Fig.  242). 
The  incision  is  now  extended  round  the  back  of  the 
expanded    supravaginal    cervix   to   meet   its   beginning   in 


Fig.  241. — Enucleating  the  base  of  the  tumour. 

front,  the  enucleation  of  the  tumour  being  meanwhile 
continued.  The  uterine  vessels  on  the  operator's  side  are 
the  last  to  be  divided,  and  can  usually  be  secured  by  the 
assistant  before  the  uterus  and  tumour  are  finally  separated 
(Fig.  243). 

vii.  Ligature  of  the  ovarian  and  uterine  vessels. — See 
pp.  301-6. 

viii.  Treatment  of  the  stump. — The  stump,  which  in 
these  cases  consists  of  the  expanded  supravaginal  cervix 


Fig  243. — Final  stage  of  amputation. 


346 


GYNECOLOGICAL  SURGERY 


surrounding  the  cavity  from  which  the  tumour  has  been 
enucleated,  is  now  trimmed  up  with  scissors,  all  redundant 
tissue  being  removed  and  the  cavity  obliterated  with 
mattress-sutures    (Fig.   244). 

ix.  Suturing  the  broad  ligaments  and  peritoneal  flaps. 
— See  p.  306. 

x.  Closing  the  abdominal  cavity. — See  p.   285. 

xi.  Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 

Difficulty. — The  surgeon  may  find  some  difficulty  in 
enucleating  the  tumour,   and  this  is  nearly  always  due  to 


Fig.  244. — Securing  the  stump  with  mattress-sutures. 

the  fact  that  his  fingers  are  not  within  the  true  capsule. 
The  commonest  error  is  to  attempt  to  peel  off  the  peri- 
toneum only ;  or,  again,  there  may  be  one  or  two  layers 
of  connective  tissue  under  the  peritoneum  which,  partly 
separating,  are  mistaken  for  the  capsule.  Lastly,  the 
incision  to  open  up  the  capsule  may  be  too  deep,  and  the 
operator  unknowingly  may  be  trying  to  separate  the  outer 
layer  of  the  tumour  from  its  deeper  parts.  If  the  right 
plane  between  the  capsule  and  the  tumour  is  identified, 
the  latter  can  generally  be  freed  quite  easily. 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    347 

If  the  tumour  has  been  or  is  inflamed,  the  capsule  may 
be  adherent  to  it,  and  the  adhesions  may  have  to  be  cut 
through. 

Advantages  of  the  method. — The  special  method  here 
described  in  detail  has  the  great  advantage  that  it  is 
applicable  to  all  cases  of  central  cervical  myoma,  whatever 
their  size.  The  enucleation  being  accomplished  within  the 
capsule,  all  danger  of  wounding  such  important  structures 
as  the  ureter,  rectum,  or  bladder  is  avoided,  whereas  an 
attempt  to  perform  total  hysterectomy  by  the  usual  method 
will  be  fraught  with  a  risk  to  those  structures  that  increases 
pari  passu  with  the  size  and  fixity  of  the  tumour. 

Total  hysterectomy  for  a  central  cervical  myoma. — 
Occasions  may,  however,  arise  when  it  is  desirable  to  remove 
the  whole  uterus.  In  such  a  case,  if  the  parts  are  lax, 
and  the  tumour  is  small  and  rides  up  after  division  of  the 
peritoneum  so  that  the  vaginal  wall  becomes  accessible, 
the  growth  may  be  successfully  removed  on  the  lines  pre- 
viously indicated  for  the  ordinary  method  of  performing 
panhysterectomy.  Where  this  is  not  possible  and  yet  the 
ablation  of  the  whole  uterus  is  desirable,  the  object  is  best 
attained  by  separately  excising  the  expanded  cervical 
stump  after  the  removal  of  the  tumour  and  the  upper  part 
of  the  uterus  has  been  carried  out  by  the  method  already 
described. 

The  removal  of  the  cervical  stump  is  effected  by  the 
same  technique  as  that  described  under  Total  Hysterectomy 
(p.  319),  the  vagina  being  first  opened  either  in  front  or 
behind,  as  appears  most  convenient  to  the  operator. 

II.     HYSTERECTOMY      FOR     CERVICAL      MYOMA, 
WITH     TOTAL     ENUCLEATION     BY     TRANS- 
VERSE  INCISION 
Indications. — This  method  may  be    chosen    when    the 
myoma    enucleates    with    great    ease    and    without    much 
haemorrhage.      It  is   also   indicated  when  the  myoma  has 
caused  great  enlargement  of  the  cervix  and  it  is  desired 


348 


GYNECOLOGICAL  SURGERY 


to  reduce  its  bulk  before  proceeding  with  the  hyster- 
ectomy. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity- — See 
p.   276. 

ii.  Insertion  of  the  large  swab. — See  p.  293. 

iii.  Clamping  and  dividing  the  ovarian  vessels  and 
round  ligaments. — See  p.  293-96. 


Fig.  245. — Hysterectomy  for  cervical  myoma,  with  total 
enucleation  by  transverse  incision  :  Enucleating  the 
whole  tumour. 

iv.  Dissecting  down  to  the  anterior  flap  of  peritoneum. 

— See  pp.  296-98. 

v.  Incising  the  capsule  and  enucleating  the  tumour. 
— After  the  anterior  flap  of  peritoneum  and  the  bladder 
have  been  turned  down,  the  uterus  is  pulled  up  with 
a  volsella,  and  an  incision  is  made  across  the  anterior 
surface  of  the  expanded  supravaginal  cervix  through  the 
capsule  of  the  tumour.  With  the  fingers  of  the  right  hand 
the  surgeon  then  gradually  enucleates  the  entire  tumour, 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    349 

pulling   upon   it   at    the    same   time   with   a   volsella  held 
in  the  left  hand  (Fig.  245). 

vi.  Clamping  the  uterine  arteries  and  amputation  of 
the  uterus. — The  uterus  with  its  collapsed  supravaginal 
cervix  can  now  easily  be  pulled  out  of  the  abdominal  cavity. 
The  lower  edge  of  the  incised  capsule  being  secured  with 
pressure-forceps  which  the  surgeon  holds  in  his  left  hand, 
the  assistant  pulls  on  the  uterus,  and  the  surgeon,  having 
clamped  both  uterine  arteries,  amputates  the  uterus  with 


Fig.  246. — Amputating  the  uterus. 

a  pair  of  scissors  (Fig.  246).  Whether  a  panhysterectomy 
or  a  subtotal  is  done  depends  rather  upon  how  much  the 
vagina  has  been  stretched.  As  the  uterus  is  being  ampu- 
tated the  surgeon  will  find  either  that  he  is  cutting  through 
the  vagina,  in  which  case  a  panhysterectomy  will  be  per- 
formed, or  that  he  is  cutting  through  a  very  dilated  supra- 
vaginal cervix,  in  which  case  the  hysterectomy  is  subtotal, 
for  it  is  often  difficult  to  distinguish  between  the  collapsed 
cervix  and  the  vagina.  In  either  case,  after  the  uterus  is 
removed  two  cavities  will  be  seen.  One,  the  expanded 
supravaginal  cervix  or  the  vagina,  and  the  other — which 


35o 


GYNAECOLOGICAL  SURGERY 


may  lie  in  front,  behind,  or  to  the  side  of  it — the  lower 
pole  of  the  capsule  of  the  tumour  (Fig.  247).  The  tumour 
cavity  is  now  closed  by  a  series  of  mattress-sutures,  which 
should  also  be  made  to  occlude  the  cervical  canal  if  the 
amputation  has  been  subtotal.  If  the  whole  uterus  has 
been  removed,  it  is  better  to  leave  the  vagina  open  and 
merely  suture  the  peritoneum  over  it. 

vii.  Ligaturing  the  uterine  and  ovarian  arteries  and 
round  ligament  and  suturing  the  peritoneal  flaps. — See 
pp.  301-07. 


Fig.  247. — Treatment  of  the  stump. 

viii.  Closing  the  abdominal  cavity- — See  p.  285. 

Dangers. — See  p.  323. 

Dressings  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 

III.     HYSTERECTOMY    FOR   A    CERVICAL    MYOMA 
BY    HEMISECTION    OF    THE    UTERUS 

General  remarks. — Some  cervical  myomata  are  best 
removed  by  hemisection  of  the  uterus  followed  by  hysterec- 
tomy. This  method  is  particularly  indicated  when  the 
tumour,  either  central  or  posterior,  raises  the  bladder  so 
that  on  the  abdomen  being  opened  the  utero-vesical  pouch 
is  found  obliterated  and  the  uterus  is  so  covered  by  the 


HYSTERECTOMY  FOR  CERVICAL  MYOMA   351 

bladder  that  only  its  fundus  presents.  In  such  cases  it  is 
impossible  to  adopt  the  method  of  transverse  section  of 
the  capsule  previously  described,  as  the  intervening  bladder 
cannot  be  sufficiently  pushed  down. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation.  i.  Abdominal  incision. — The  abdominal 
cavity  is  opened  by  the  method  described  at  p.  276, 
particular  care  being  taken  not  to  wound  the  bladder, 
which  is  much  raised  in  these  cases. 


Fig.  248. — Hysterectomy  for  a  cervical  myoma  by  hemisection 
of  the  uterus  :     Separating  the  bladder. 


ii.  Separation  of  the  bladder. — The  round  ligaments  on 
each  side  having  been  clamped  with  pressure-forceps,  an 
incision  is  made  from  one  to  the  other  at  the  level  of  the 
upper  limit  of  the  loose  attachment  of  the  peritoneum 
where  it  is  stretched  over  the  tumour  and  the  anterior 
surface  of  the  uterus.  The  peritoneum,  together  with  the 
bladder,  is  now  pushed  downwards  as  far  as  possible  from 
off  trie  face  of  the  expanded  supravaginal  cervix  with  a 
swab  (Fig.  248). 

iii.  Hemisection  of  the  uterus. — Pressure-forceps  are 
next  applied  to  the  upper  edges  of  the  broad  ligaments  so 
as  to  control  the  ovarian  vessels.    The  operator  then  seizes 


352 


GYNAECOLOGICAL  SURGERY 


the  fundus  on  each  side  with  volsella  forceps  ;  he  hands 
the  left  pair  of  forceps  to  an  assistant,  and,  grasping  the 
right  pair  in  his  left  hand,  steadies  the  uterus  and  divides 
the  body  in  half  with  a  scalpel,  the  incision  being  carried 
downwards  well  into  the  tumour  so  that  the  plane  of  its 
capsule  is  easily  made  out  (Fig.  249). 

iv.  Enucleating  the  tumour. — The  capsule  having  been 


Fig.  249. — Hemisection  of  the 
uterus. 


defined,  the  tumour  is  seized  with  a  volsella  and  enu- 
cleated entire  by  means  of  the  fingers  (Fig.  250). 

v.  Amputation  of  the  uterus. — The  partially-divided 
uterus  with  the  collapsed  cervix  is  next  removed  by  the 
method  described  at  p.  349,  the  amputation  taking  place 
either  through  the   cervix  or  through  the  vagina. 

vi.  Closing  the  abdominal  cavity. — See  p.  285. 

Dangers. — Those  described  at  p.  323. 

Dressing  and  after-treatment. — See  p.  44   and  Chapter 

XXXII. 


^Kz-t-^t^/s^jf. 


Plate  V. — Myoma  of  the  Anterior  Uterine  Wall  and  Cervix. 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    353 

IV.  HYSTERECTOMY  FOR  AN  ANTERIOR 
CERVICAL  MYOMA 
General  remarks. — An  anterior  cervical  myoma  takes 
up  one  of  two  positions :  either  it  undermines  the  bladder 
and  elevates  it  on  its  upper  surface,  or  it  forces  its  way 
up  between  the  peritoneum  covering  the  posterior  wall  of 
the  bladder  and  the  musculature  of  the  viscus.  In  the 
first  case,  unless  the  displacement  of  the  bladder  is  appre- 


Fig.  250. — Enucleating  the  tumour 


ciated,  it  will  stand  a  good  chance  of  being  wounded  when 
the  parietal  incision  is  made.  In  the  second  case,  unless 
all  the  loose  peritoneum  covering  the  front  surface  of  the 
expanded  supravaginal  cervix  and  uterus  is  utilised  in 
the  formation  of  the  anterior  peritoneal  flap,  it  will  be 
found  that  at  the  close  of  the  operation  there  is  in- 
insufficient  peritoneum  to  cover  the  denuded  posterior  wall 
of  the  bladder  and  the  upper  surface  of  the  stump.  It 
should  also  be  borne  in  mind  that  the  round  ligaments, 
x 


354 


GYNECOLOGICAL  SURGERY 


especially  in  the  case  of  the  anatomical  displacement  first 
mentioned,  may  be  so  elevated  that  they  form  the  highest 
ridge  in  the  broad  ligament,  and  that  by  the  tumour  bulging 
into  the  wound  and  retroverting  the  body  of  the  uterus 
the  landmarks  of  the  ovary  and  the  Fallopian  tubes  are 
hidden  from  the  operator.  In  these  circumstances  we  have 
seen  the  round  ligaments  mistaken  for  the  fold  containing 
the  ovarian  vessels,  and  clamped  and  divided  as  such, 
with  the  result  that  this  division,  being  extended  too  far 
forwards,  has  opened  the  elevated  bladder. 


Fig.  251. — Hysterectomy   for   anterior   cervical    myoma  : 
Dividing  the  peritoneum  over  the  front  of  the  tumour. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity.  —  See 
p.  276. 

ii.  Insertion  of  large  swab. — See  p.  293. 

iii.  Clamping  the  round  ligaments. — The  round  liga- 
ments, having  been  very  carefully  defined  and  their  relation 
to  the  bladder  made  out,  are  clamped  and  divided  close 
to  their  attachment  to  the  uterus   (Fig.  251). 

iv.  Incising  the  peritoneum  and  capsule  over  the 
tumour. — The  peritoneum  covering  the  expanded  supra- 
vaginal cervix  is  now  divided  at  the  upper  limit  of  its  loose 


HYSTERECTOMY  FOR  CERVICAL  MYOMA   355 

attachment  to  the  uterus,  this  point  being,  if  necessary, 
defined  beforehand  by  undermining  the  peritoneum  with 
the  finger.  The  incision  commences  on  the  left-hand  side 
just  where  the  round  ligaments  are  clamped,  and  extends 
to  a  similar  point  on  the  other  side  (Fig.  251).  The  anterior 
peritoneal  flap  is  now  pushed  off  the  surface  of  the  expanded 
supravaginal  cervix  until  the  reflection  of  the  bladder  is 


Fig.  252. — Enucleating  the  base  of  the  tumour. 

reached,  and  the  capsule  of  the  tumour  is  then  divided  just 
above  the  level  of  the  bladder  attachment. 

v.  Enucleation  of  the  base  of  the  tumour. — The  peri- 
toneum and  capsule  are  now  together  carefully  pushed  off 
the  face  of  the  tumour,  the  base  of  which  is  gradually 
enucleated  with  the  first  and  second  fingers  of  the  right 
hand,  care  being  taken  not  to  injure  the  bladder.  This 
enucleation  is  assisted  by  fixing  the  volsella  to  the  tumour 
and  pulling  on  this  with  the  left  hand  (Fig.  252). 

vi.  Division    of  the   broad   ligaments,    etc. — When  the 


356 


GYNECOLOGICAL  SURGERY 


base  of  the  tumour  is  enucleated  the  volsella  is  transferred 
to  the  uterus,  which  is  pulled  up,  the  ovarian  vessels  are 
clamped  and  the  broad  ligaments  divided  (Fig.  253). 

vii.  Clamping  the  uterine  vessels  and  amputation  of 
the  uterus. — The  volsella  is  again  fixed  to  the  tumour, 
which  together  with  the  uterus  is  drawn  out  of  the  wound. 


Fig.  253. — Clamping  the  ovarian  artery. 

The  uterine  vessels  are  then  clamped  on  each  side  and 
the  uterus  amputated  through  the  cervix  with  a  scalpel 
(Fig.  254).  If  a  total  hysterectomy  is  desired,  the  anterior 
vaginal  wall  should  first  be  opened,  as  described  at  p.  332. 

viii.  Ligaturing  the  vessels. — See  pp.  301-06. 

ix.  Treatment  of  the  stump. — See  p.  344. 

x.  Suturing  the  peritoneal  flaps. — See  p.  306. 

xi.  Closing  the  abdominal  cavity. — See  p.  285. 

Dangers. — Those  described  on  p.  323. 

Dressing  and  after-treatment. — See  p.  44  and    Chapter 

XXXII. 


HYSTERECTOMY  FOR  CERVICAL  MYOMA    357 


V.     HYSTERECTOMY  FOR  A  POSTERIOR  CERVICAL 

MYOMA 

General  remarks. — The  methods  of  dealing  with  a 
posterior  cervical  myoma  are  two,  depending  upon  its 
variet}'  as  described  at  p.  338.     If  the  rarer  form  therein 


Fig.  254. — Clamping  the  uterine  artery. 

described  is  present,  when  the  tumour,  undermining  the 
peritoneum  at  the  bottom  of  Douglas's  pouch,  strips  the 
serous  membrane  off  the  anterior  face  of  the  sacrum  and 
rectum,  the  uterus  will  be  found  to  have  been  bodily 
elevated  on  the  myoma  in  a  position  of  retroversion.  In 
this  case  the  cervix  and  the  upper  part  of  the  vagina  are 
the  most  accessible  parts  at  which  to  commence  the  ampu- 
tation, and  it  will  be  found  best  to  adopt  the  technique 


358 


GYNECOLOGICAL  SURGERY 


of  an  operation  devised  by  one  of  us  for  such  conditions 
{see  p.  331). 

If  the  tumour  be  of  the  commoner  variety,  namely,  that 
bulging  back  into  the  pouch  of  Douglas,  the  method  about 
to  be  described  should  be  followed. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation,   i.  Opening  the  abdominal  cavity. — See  p.  276. 


Fig.  255. — Hysterectomy  for  a  posterior  cervical  myoma  : 
Incising  the  peritoneum  and  the  tumour-capsule. 

ii.  Insertion  of  large  swab. — See  p.  293. 

iii.  Clamping  and  dividing  the  ovarian  vessels  and  round 
ligaments. — The  ovarian  vessels  and  round  ligaments  are 
clamped  and  divided  as  described  at  pp.   293-96. 

iv.  Incising  the  peritoneum  and  capsule.  —  The  peri- 
toneum and  capsule  at  the  junction  of  the  tumour  with  the 
posterior  surface  of  the  uterus  are  incised  and  reflected 
(Fig.  255). 

v.  Enucleation  of  the  base  of  the  tumour. — The  fingers 
being  now  forced  between  the  capsule  and  the  tumour,  the 
latter  is  partially  enucleated  (Fig.  256). 


HYSTERECTOMY  FOR  CERVICAL  MYOMA   359 


Fig.  256.— Enucleating  the 
base  of  the  tumour. 


Fig.  257.— Clamping  the  uterine  vessels. 


360  GYNAECOLOGICAL  SURGERY 

vi.  Reflecting  the  anterior  flap  of  peritoneum. — The  peri- 
toneum over  the  anterior  surface  of  the  supravaginal  cervix 
is  next  reflected,  as  described  at  pp.  296-98. 

vii.  Clamping  the  uterine  vessels  and  amputating  the 
uterus. — Strong  traction  is  now  made  on  the  tumour, 
which,  together  with  the  freed  uterus,  can  be  easily  pulled 
up  with  a  volsella  so  that  the  uterine  vessels  on  each 
side  are  brought  into  view  and  then  clamped  (Fig.  257), 
after  which  the  uterus  is  amputated  in  the  usual  way 
described  for  subtotal  hysterectomy,  or,  if  total  removal  is 
desired,  then  by  first  opening  the  anterior  vaginal  vault. 

viii.  Ligaturing  the  ovarian  and  uterine  vessels. — See 
pp.  301-06. 

ix.  Treatment  of  the  stump. — If  the  posterior  peritoneal 
flap  and  the  capsule  of  the  tumour  are  redundant,  as  they 
usually  are,  they  are  trimmed  up  with  scissors,  after  which 
the  stump  is  sutured  in  the  manner  described  at  p.  344. 

x.  Suturing  the  peritoneal  flaps. — See  p.  306. 

Dangers. — Those  described  on  page  323. 

Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 


CHAPTER    XVII 

THE    RADICAL    ABDOMINAL    OPERATION    FOR 
CARCINOMA    OF   THE    CERVIX 

Wertheim's  radical  operation  for  cancer  of  the  cervix 
consists  in  removing,  through  an  abdominal  incision,  the 
uterus  and  its  appendages  and,  by  means  of  clamps,  suffi- 
cient vagina  to  form  a  bag  in  which  the  diseased  cervix 
can  be  encapsuled.  In  addition,  the  parametrium  and  as 
much  connective  tissue  of  the  pelvis  as  possible  are  dissected 
out,  together  with  as  many  regional  glands  as  the  operator 
may  deem  advisable. 

W.  A.  Freund,  in  1878,  was  the  first  to  advocate  abdo- 
minal hysterectomy  for  cancer  of  the  uterus,  but  it  is  to 
Ries,  of  Chicago,  that  we  owe  the  development  of  the 
radical  operation  as  it  is  practised  to-day.  In  1895,  Ries, 
by  operating  on  dogs  and  cadavers,  satisfied  himself  and 
others  that  it  would  be  possible  to  remove  the  uterus  and 
its  appendages,  the  cellular  tissue  of  the  pelvis,  and  the 
lymphatic  glands  as  far  as  the  bifurcation  of  the  common 
iliac,  without  killing  the  patient.  Clark,  in  1896,  put  this 
suggestion  into  practice  on  the  living  woman  at  the  Johns 
Hopkins  Hospital,  and  his  example  was  quickly  followed 
by  others,  among  whom  may  be  mentioned  Werder,  Rump, 
Mackenrodt,  and  Wertheim.  It  is,  however,  to  Wertheim 
that  we  owe  the  present  position  of  this  operation,  which 
he  has  performed  as  a  routine  one  for  a  much  longer  period 
and  in  far  greater  numbers  than  any  other  surgeon,  and 
his  results  are  the  most  interesting  we  have.  It  is  to  be 
noted,  however,  that  although  in  England,  at  any  rate, 
the  radical  operation  is  known  by  Wertheim's  name,  the 
only  point  in  its  procedure  that  he  invented  is  the  appli- 
cation of  the  vaginal  clamp. 

361 


362  GYNECOLOGICAL  SURGERY 

What  advantages  has  Wertheim's  operation  over 
simple  yaginal  hysterectomy  ? — We  must  discuss  this  ques- 
tion under  four  headings  : — 

i.  The  operation  from  the  pathological  standpoint. 

2.  Primary  mortality. 

3.  Percentage  operability. 

4.  Percentage  of  cures. 

1.  The  operation  from  a  pathological  standpoint. — 
From  this  point  of  view  we  believe  that  the  value  of  the 
procedure  is  manifest.  The  advance  of  a  carcinomatous 
growth  takes  place  in  two  ways  :  first,  by  a  gradual  pressure- 
destruction  of  the  tissue  surrounding  it,  "infiltration"; 
and,  secondly,  by  a  growth-insinuation  along  trunk  lym- 
phatic channels,  "  permeation."  The  distinction  between 
these  two  methods  of  growth  has  lately  been  insisted  on 
by  Sampson  Handley,  and  is  very  important.  The  first 
is  seen  at  the  rnacroscopical  growing  edge,  where  a  remark- 
ably abrupt  line  between  the  carcinoma  and  the  surrounding 
tissues  is  exhibited.  The  second  is  evidenced  by  the  car- 
cinomatous lymphatic  glands  and  secondary  nodules  occur- 
ring at  a  distance  from  the  primary  growth.  The  distinction 
is  exemplified  by  the  clinical  course  of  a  rodent  ulcer  and 
an  epithelioma  respectively.  In  the  first  we  have  a  growth 
by  infiltration  alone  ;  in  the  second,  both  by  infiltration 
and  permeation.  Had  we  to  deal  with  a  tumour  growing 
solely  by  infiltration,  it  would  be  possible  permanently  to 
remove  it  by  an  incision  just  outside  its  abrupt  rnacro- 
scopical margin  ;  but  growth  by  permeation  requires  a 
wide  removal  of  the  entire  lymphatic  tract  to  render  it 
successful.  Growth  by  infiltration  is  occurring  around  the 
whole  periphery  of  a  carcinoma,  but  growth  by  permeation 
only  along   certain  well-defined   lymphatic   channels. 

Applying  these  general  considerations  to  carcinoma  of 
the  cervix,  we  see  that  the  distinction  between  these  different 
methods  of  growth  is  well  preserved.  Thus,  the  bladder, 
rectum,  and  vagina  are  involved  by  infiltration,  a  slow 
process  taking  many  months  or  a  year  or  two  to  cross  the 


WERTHEIM'S  OPERATION  363 

short  length  of  tissue  that  separates  them  from  the  cervix. 
The  pelvic  glands,  on  the  other  hand,  are  involved  by 
permeation,  a  much  faster  method  of  extension,  by  which 
the  many  inches  of  tissue  intervening  between  them  and 
the  primary  growth  may  be  spanned  in  a  few  weeks.  Now, 
the  lines  of  lymphatic  conduction  in  the  case  of  the  cervix 
are  few  and  simple,  and  run,  as  we  have  shown,  straight 
outwards  through  the  parametrium  to  the  external  iliac 
glands. 

The  demands  of  pathology  are  therefore  satisfied  by 
an  excision  so  planned  as  to  include  this  tract,  while  keeping 
just  outside  the  periphery  of  the  macroscopic  growing 
edge  elsewhere.  Wertheim's  operation  does  this  and  more  ; 
and  it  is,  therefore,  a  rational  treatment,  even  where  the 
edge  of  the  growth  is  separated  from  the  bladder  or  rectum 
by  one-twentieth  of  an  inch  of  uninfiltrated  tissue.  But 
growth  by  permeation  does  not  always  occur  in  these 
patients,  for  of  all  the  common  sites  of  carcinoma  the 
cervix  is  that  in  which  metastases  (and  therefore  growth 
by  permeation)   are  least  common. 

2.  Primary  mortality. — The  primary  mortality  of  Wert- 
heim's operation  is  undoubtedly  high.  With  increased 
experience  it  can  be  lowered.  Wertheim's  results  are  an 
example  of  this.  In  his  first  200  cases  there  were  50 
deaths ;  in  his  last  258  cases,  35  deaths.  In  his  first  30 
cases  the  mortality  was  40  per  cent.  ;  in  his  last  30  cases 
it  was  7  per  cent.  His  total  mortality  to  date  is  i5-2  per 
cent.  In  a  paper  read  by  one  of  us  at  the  Medical  Society 
of  London  in  1909  it  was  shown  that  the  mortality  of 
243  cases  of  Wertheim's  operation  performed  by  British 
surgeons  was  18*1  per  cent.  Doderlein  publishes  a  list 
of  715  operations  with  a  mortality  of  14*8  per  cent. ; 
he  gives  his  own  primary  mortality  for  65  cases  as  18*7 
per  cent.  Schindler,  of  Graz,  has  a  mortality  of  9  per 
cent.  Bumm  had  a  mortality  of  25  per  cent.,  but,  having 
improved  his  technique,  it  has  fallen  to  15  per  cent.  The 
mortality  of  all  the  cases  of  radical  abdominal  operations 


364  GYNAECOLOGICAL  SURGERY 

performed  in  the  British  Isles  that  one  of  us  has  collected, 
313  in  number,  is  18*5  per  cent. 

The  mortality  for  simple  vaginal  hysterectomy  is 
naturally  lower.  Schauta  gives  the  following  statistics  for 
vaginal  hysterectomy  :  Waldstein  (Schauta),  10-3  per  cent.  ; 
Hocheisen  (Gusserow),  14-4  per  cent. ;  Krukenburg  (Ols- 
hausen),  127  per  cent.  ;  Zurhelle  (Fritsch),  6*6  per  cent. 
Doderlein  reports  4,368  vaginal  hysterectomies  with  a 
mortality  of  9*1  per  cent.  Hirschmann  collected  1,241  cases 
with  a  mortality  of  8'8  per  cent. ;  Fehling,  770  cases  with  a 
mortality  of  0/6  per  cent.  Percentages  smaller  than  these 
have  been  reported — by  Leopold,  57  per  cent.,  and  by 
Amann,  4  per  cent. 

In  England  the  experience  of  some  of  those  who  have 
performed  vaginal  hysterectomy  to  a  large  extent  has 
been  more  favourable  than  this,  but  the  operability  rate 
in  this  country  is  lower  than  that  on  the  Continent.  The 
fact  that  the  radical  abdominal  operation  has  a  higher 
primary  mortality  should  not  of  itself  deprive  any  patient 
of  the  chance  of  cure.  Moreover,  this  increased  mortality 
is  mostly  because  cases  of  a  much  more  advanced  or  serious 
nature  can  be  and  are  treated  by  this  method.  It  is, 
therefore,  unfair  to  compare  the  primary  mortality 
of  the  radical  abdominal  operation  with  that  of  vaginal 
hysterectomy,  which  can  only  be  performed  in  early  cases. 
If  the  percentage  mortality  is  reckoned  according  to 
whether  the  case  is  one  of  an  early,  moderate,  or  advanced 
nature,  we  find  in  238  of  the  "  Wertheim's  "  which  we 
have  collected  the  following  results  : — ■ 

In  186  advanced  cases,  23*1  per  cent. 
In  19  moderate  cases,  5 '2  per  cent. 
In  33  early  cases,  6*3  per  cent. 

These  results  bear  out  our  belief  that  the  mortality  of 
this  operation  is  not  appreciably  higher  than  that  of  simple 
vaginal  hysterectomy,  if  only  cases  of  a  similar  nature 
are  operated  on. 


WERTHEIM'S  OPERATION  365 

Although  every  effort  must  be  made  to  reduce  the 
primary  mortality  of  Wertheim's  operation,  still,  in  a 
comparison  of  the  merits  of  these  two  operations,  we  are 
distinctly  of  the  opinion  that  too  much  should  not  be 
made  of  the  greater  mortality.  If,  after  a  period  of  five 
years,  there  are  appreciably  more  patients  alive  out  of 
every  hundred  operated  upon  by  this  method  than  out 
of  every  hundred  operated  upon  by  simple  vaginal  hys- 
terectomy, then,  in  spite  of  the  primary  mortality,  the 
end  justifies  the  means. 

3.  Percentage  operability. — The  percentage  operability 
is  greatly  increased  by  the  radical  abdominal  operation 
because  the  bladder,  rectum,  and  ureter  can  be  separated 
from  the  growth  without  much  risk  of  injury,  whereas  in 
simple  vaginal  hysterectomy  in  a  large  number  of  cases 
this  is  impossible. 

It  has  been  argued  that  the  percentage  operability  can 
be  made  as  large  as  any  operator  chooses  if  he  operates 
upon  cases  in  which  there  is  no  chance  of  cure.  Up  to  a 
certain  point  no  doubt  this  criticism  is  just,  but  we  do  not 
think  it  entirely  meets  the  case.  It  is,  as  we  shall  see, 
difficult  to  determine  beforehand  in  which  patients  there 
is  a  chance  of  cure.  All  are  agreed  that,  if  only  early  cases 
are  chosen,  the  percentage  of  cures  will  be  much  greater 
and  the  mortality  much  less.  Still,  it  is  evident  that 
most  operators  have  not  limited  themselves  in  this  way, 
with  the  result  that  many  women  have  been  cured  whose 
chances  from  a  clinical  examination  might  have  been 
thought  to  be  hopeless.  According  to  Doderlein  and 
Kronig,  the  average  percentage  operability  of  ten  opera- 
tors by  the  radical  abdominal  method  was  68.  Wertheim 
has  operated  upon  49  per  cent,  of  his  cases,  Schindler 
46  per  cent.,  and  Bumm  90  per  cent. ;  but  this  latter  figure 
must  be  due  to  the  fact  that  Bumm  has  operated  on  cases 
that  most  other  surgeons  would  refuse — a  surmise  which 
is  perhaps  warranted  by  his  heavy  primary  mortality. 
We  have  noted  every  case  of  cancer  of  the  cervix  both 


366  GYNECOLOGICAL  SURGERY 

in  the  in-  and  out-patient  departments  of  the  Middlesex 
and  Chelsea  Hospitals,  and  also  the  private  cases  that 
we  have  seen  during  1908  and  1909,  and  our  percentage 
operability  during  this  period  has  been  67.  The  average 
percentage  operability  for  vaginal  hysterectomy  is  much 
smaller,  and  although  Gusserow,  Olshausen,  Kaltenbach, 
Leopold,  Kuestner,  and  Doderlein  return  a  percentage  of 
31,  that  of  Chrobak  and  Schauta  is  15,  and  of  Waldstein 
147,  these  last  being  more  in  accord  with  the  experience 
of  English  operators,  which  is  nearer  12. 

4.  Percentage  of  cures. — If  the  uterus  is  removed  by 
simple  vaginal  hysterectomy,  practically  all  the  parametrium 
is  left  behind ;  if  by  Wertheim's  method,  all  the  parame- 
trium and  a  large  portion  of  the  cellular  tissue  of  the  pelvis 
are  taken  away.  The  results  of  the  pathological  investiga- 
tion of  the  parametrium  extending  over  a  large  number  of 
cases,  and  including  the  microscopical  examination  of  some 
thousands  of  sections,  prove  conclusively  to  our  minds 
that  this  structure  should  always  be  removed.  Schauta 
found  that  the  parametrium  was  infected  in  69  per  cent, 
of  his  cases,  Wertheim  in  60  per  cent.,  Kundrat  in  55  per 
cent.,  Baisch  in  50  per  cent.  ;  and  many  other  observers 
have  similar  records.  In  at  least  half  the  cases,  therefore, 
simple  vaginal  hysterectomy  is  useless,  because  cancerous 
tissue  is  left  behind. 

These  facts  do  not  carry  much  weight  with  those  who 
favour  vaginal  hysterectomy,  because  they  argue  that  if, 
on  clinical  examination,  the  parametrium  is  found  to  be 
involved,  no  method  of  removal  is  satisfactory ;  whereas, 
if  the  uterus  is  quite  mobile  and  the  parametrium  is  felt 
to  be  soft,  vaginal  hysterectomy  holds  out  as  good  a  chance 
of  cure  as  any  other  operation.  The  pathological  findings 
have  proved  this  opinion  to  be  untenable.  It  is  impossible 
to  diagnose  clinically  the  real  condition  of  the  parametrium. 
A  hard  parametrium  may  contain  no  cancer,  a  soft  one 
may  be  full  of  cancer.  In  22*5  per  cent,  of  Wertheim's 
cases,  although  the  parametrium  felt  quite  soft,  a  marked 


WERTHEIM'S  OPERATION  367 

cancer-infection  had  taken  place ;  and  in  14  per  cent, 
where  the  parametrium  felt  quite  hard,  no  infection  had 
occurred,  the  induration  being  due  to  inflammatory  reaction. 
Kundrat  likewise  found  the  parametrium  infected  in  16  per 
cent,  of  his  cases  in  which  clinically  it  appeared  to  be  free. 
It  is  almost  impossible  to  estimate  accurately  the  per- 
centage of  cures  in  this  country,  because  of  the  difficulty 
in  tracing  hospital  patients.  It  is  much  easier  abroad  to 
keep  in  touch  with  patients,  since  the  police  keep  a  record 
of  where  people  live  and  when  they  change  their  addresses. 
The  German  method  of  estimating  cures  is  a  very  strict 
one,  including,  as  it  does  by  Winter's  method,  the  number 
of  cases  per  hundred  operated  upon,  added  to  the  number 
of  patients  per  hundred  remaining  well,  the  result,  divided 
by  one  hundred,  being  called  the  "  absolute  cure  "  for 
the  number  of  cases  taken.  Five  years  seems  to  be 
the  period  chosen  by  most  authorities,  after  which  the 
patient  may  be  said  to  be  cured  as  far  as  her  original 
disease  goes. 

The  statistics  we  have  collected  for  this  country  are 
useless  for  the  purpose  under  discussion,  as  nearly  all  the 
operations  have  been  performed  within  the  last  year  or 
two.  On  the  Continent,  however,  a  large  number  of 
cases  have  accumulated  that  now  fulfil  this  standard. 
Wertheim  has  138  women  alive  operated  upon  more 
than  five  years  ago,  which  equals  a  percentage  cure  of  62. 
Polosson  has  60  per  cent,  free  of  recurrence  after  five 
years,  Mackenrodt  45  per  cent.,  Bumm  30  per  cent.  When 
we  compare  this  with  the  percentage  of  cures  by  vaginal 
hysterectomy,  a  very  great  difference  is  at  once  notice- 
able. With  cases  of  carcinoma  of  the  cervix,  we  find  that 
Jacobs  had  1*2  per  cent.,  Gusserow  2-5  per  cent.,  Olshausen 
6-6  per  cent.,  Kustner  0/2  per  cent.,  Kaltenbach  9/2  per 
cent.,  Leopold  8*2  per  cent.,  Doderlein  and  Pozzi  9  per 
cent.,  and  Polosson  12  per  cent,  of  patients  living  after 
five  years,  so  that  apparently  not  one-tenth  of  the  cases 
operated   upon   by   vaginal   hysterectomy   are    alive    after 


368  GYNECOLOGICAL  SURGERY 

this  period.  Frommer  had  35*6  per  cent,  recurrences  in 
the  first  year,  Zweifel  69/8  per  cent,  in  the  first  six  months, 
and  Winter,  out  of  148  cases,  had  115  recurring  the  first 
year,  13  in  the  second,  13  in  the  third,  5  in  the  fourth, 
and  2  in  the  fifth.  Segan,  out  of  49  cases,  had  only  2 
living  after  five  years ;  Bouilly  had  yj  per  cent,  of 
recurrences  with  17  cases ;  Waldstein,  out  of  274  cases, 
had  only  4  living  after  five  years ;  and  there  are 
many  other  records  with  the  same  tale.  English  operators 
have  been  more  successful  than  this,  as,  for  instance, 
Spencer  and  Lewers  with  24  per  cent,  and  16  per  cent, 
of  cures  respectively  after  five  years.  It  must  be  remem- 
bered, however,  that  foreign  statistics  deal  with  thousands 
of  cases,  whereas  our  English  ones  deal  with  hundreds. 
In  comparison  with  vaginal  hysterectomy,  therefore,  the 
percentages  of  cures  in  the  case  of  Wertheim's  and 
other  radical  abdominal  operations  show  a  remarkable 
improvement. 

This  increase  in  the  number  of  cures  by  the  radical 
abdominal  operation  is  due  entirely  to  two  factors.  One 
we  have  already  discussed,  namely,  the  thorough  removal 
of  the  parametrium  and  the  adjacent  connective  tissue. 
The  other  is  due  to  the  means  taken  for  preventing  any 
part  of  the  wound  from  being  contaminated  by  the  growth 
— that  part  of  the  operation,  in  fact,  with  which  Wertheim's 
name  is  particularly  associated,  i.e.  clamping  the  vagina 
well  below  any  growth  before  dividing  it,  so  that  the 
diseased  cervix  is  removed  in  a  bag  of  vagina,  and  the 
risk  of  local  implantation  of  cancer  cells  on  the  cut  edges 
of  this  canal  is  practically  eliminated. 

In  the  past  the  recurrence  of  cancer  after  the  removal 
of  the  diseased  cervix  has  nearly  always  been  local,  due 
to  cell-implantation  on  the  cut  edges  of  the  wound,  or 
to  an  imperfect  removal  of  the  parametrium.  Winter 
reports  recurrence  in  the  vaginal  scar  in  54  out  of  58 
cases,  Mangiagalli  in  114  out  of  115  cases.  Most  other 
operators    have   had  a  similar  experience   to   record.     On 


WERTHEIM'S   OPERATION  369 

the    other    hand,  with  Wertheim's  operation   local    recur- 
rence is  a  rarity. 

The  standpoint  from  which  any  operation  must  be 
gauged  is  its  ultimate  result  with  regard  to  the  cure  of  the 
greatest  number  of  patients.  Even  if,  therefore,  the  per- 
centage of  cures  with  Wertheim's  operation  were  not 
greater  than  that  by  the  simple  vaginal  method,  neverthe- 
less it  would  be  the  better  operation  because  of  the  increased 
operability,  since  a  greater  number  of  patients  would  be 
saved.  But,  further,  the  percentage  of  cures  by  vaginal 
hysterectomy  is  a  very  low  one,  whereas  that  by  the  radical 
abdominal  methods  may,  we  think,  in  comparison,  be 
termed  high. 

Archibald  Leitch  found,  from  an  investigation  of  900 
cases  of  carcinoma  of  the  cervix  that  had  not  been  operated 
upon,  that  the  average  duration  of  the  disease,  from  the 
earliest  symptoms  to  death,  was  one  year  and  nine  months.* 

About  six  months  may  be  taken  as  the  average  period 
between  the  first  appearance  of  the  symptoms  and  the 
report  of  the  patient  to  her  medical  man,  so  that  one  year 
and  three  months  is  the  average  life-expectation  of  these 
patients  if  not  operated  upon.  This  period  in  most  persons 
is  one  of  more  or  less  acute  mental  distress,  and  it  there- 
fore appears  to  us  that  the  gain  of  a  period  of  hopeful 
life,  in  any  event,  to  the  patient  who  recovers  from  the 
radical  operation,  is  one  of  the  principal  justifications  for 
its  performance. 

The  only  point  in  favour  of  simple  vaginal  hysterectomy 
is  its  low  mortality,  although,  as  we  have  pointed  out, 
if  we  take  similar  cases  the  difference  between  this  and 
Wertheim's  operation  is  not  appreciable. 

Has  Wertheim's  operation  any  advantage  over  para- 
vaginal section? — By  means  of  Schauta's  paravaginal 
section  the  scope  of  vaginal  hysterectomy  in  this  disease 
can   be   much   enlarged.     This   operator   has   devised   and 

*  Fifth     Report    of     the    Middlesex    Hospital    Cancer    Investigation 
laboratories. 
Y 


370  GYNECOLOGICAL  SURGERY 

practised  a  radical  vaginal  operation  which  will  be  found 
described  on  pp.  260-71.  The  question  of  the  relative 
values  of  extended  vaginal  hysterectomy  and  the  abdominal 
operation  depends  upon  whether  there  is  any  necessity  to 
remove  the  regional  glands.  Theoretically  there  is  nothing 
to  urge  against  the  routine  removal  of  glands ;  in  fact,  all 
are  probably  agreed  that,  if  such  a  procedure  were  possible, 
this  would  be  the  right  and  proper  course  to  pursue.  As 
a  matter  of  fact,  however,  it  is  impossible  to  remove  from 
the  living  woman  all  the  glands  that  drain  the  pelvic 
organs.  It  is  open  to  anyone  to  attempt  this  removal 
on  a  cadaver,  and  he  will  find  that,  besides  being  most 
difficult,  certain  structures  have  to  be  interfered  with,  the 
disturbance  of  which  would  kill  a  living  person.  Schauta 
examined  the  regional  glands  in  60  bodies  dead  of  cancer 
of  the  uterus,  and  in  only  233  per  cent,  did  he  find  it 
technically  possible  to  remove  them.  As,  therefore,  it  is 
not  possible  to  be  certain  of  removing  all  infected  glands, 
is  it  worth  while  systematically  to  remove  any  glands  on 
the  off-chance  that  they  are  infected  and  the  only  ones 
infected  ? 

One  has  to  consider  the  subject  from  a  pathological 
as  well  as  from  a  clinical  point  of  view.  It  is  only  by 
examining  microscopically  every  gland  removed  that  we 
can  gain  any  information  worth  having  on  the  subject. 
To  judge  their  cancerous  nature  or  otherwise  from  their 
size  and  texture  has  been  proved  conclusively  to  be  a 
useless  method  of  diagnosis,  and  the  wide  discrepancy  of 
the  gland-statistics  issued  by  different  operators  is,  we 
think,  largely  due  to  the  fact  that  microscopical  examina- 
tion has  not  been  made  in  each  case.  Glands  which  are 
large  and  hard  have  often  been  found  free  of  cancerous 
infection  on  being  examined  by  the  microscope.  Doderlein 
reports  18  cases  with  enlarged  glands,  and  in  n  of  them 
cancer  was  absent.  On  the  other  hand,  glands  which 
are  so  small  and  soft  that  they  are  perhaps  overlooked 
during  the  operation,  may  be  found  to  be  full  of  cancer- 


WERTHEIM'S   OPERATION  371 

cells.  Then,  again,  the  statistics  of  glandular  infection 
vary  according  to  whether  they  have  been  calculated 
from  glands  removed  at  the  operation  or  post-mortem. 
Take  Schauta's  statistics  for  instance.  He  examined  1,182 
glands  by  means  of  160,000  serial  sections,  and  found 
that  in.  577  per  cent,  the  glands  were  affected.  But  most 
of  the  glands  were  removed  post-mortem  from  patients 
who  had  died  from  very  advanced  cancer,  when  it  would 
have  been  unjustifiable  to  have  attempted  removal  of 
the  growth.  Riechelmann  found  35  per  cent,  of  the  glands 
infected  in  86  bodies  dead  from  carcinoma  of  the  cervix. 
Archibald  Leitch,  working  in  the  Middlesex  Hospital  Cancer 
Investigation  Laboratories,  analysed  915  cases  of  carcinoma 
of  the  cervix  in  which  an  autopsy  had  been  performed, 
and  found  glandular  deposits  in  only  38*36  per  cent.,  whilst 
no  less  than  55  per  cent,  were  free  of  metastatic  growths 
in  any  situation.  MacCormac,  working  on  a  new  series  in 
the  same  laboratories,  tells  us  that  of  75  cases  he  has 
analysed,  only  33  per  cent,  had  glandular  deposits  that  cou'd 
be  demonstrated  by  the  microscope  ;  and  that  is  the  general 
experience  of  the  workers  in  these  laboratories,  amongst 
whom  one  of  us  has  had  the  honour  to  be  numbered. 

Taking  operative  statistics,  Doderlein  gives  a  list  of 
ten  operators  whose  average  percentage  is  39/9.  Wertheim 
removed  carcinomatous  glands  in  35  per  cent,  of  his  cases, 
and  Bumm  in  33*3  per  cent.  In  73  of  our  own  cases  the 
percentage  was  31,  and  in  70  English  cases  we  have 
collected,  where  a  microscopical  examination  has  been 
made,  it  was  47. 

We  think,  therefore,  we  may  take  it  that  in  at  least 
one-third  of  the  patients  who  come  to  us  some  of  the  glands 
are  infected. 

Granted  that  in  one-third  of  the  patients  who  seek 
relief  the  glands  are  affected,  is  any  advantage  gained 
by  systematically  endeavouring  to  remove  these  glands  ? 
This  question  may  be  regarded  from  several  points  of  view. 
It  can  be  argued  that  the  systematic  removal  of  the  glands 


372  GYNAECOLOGICAL  SURGERY 

may  in  many  cases  increase  the  danger  of  the  operation. 
Large  vessels  may  be  wounded  during  the  necessary  mani- 
pulations, resulting  in  the  immediate  death  of  the  patient 
from  haemorrhage,  and  at  any  rate  the  time  taken  over 
the  operation  is  often  increased,  sometimes  markedly  so, 
and  time  in  these  cases  is  of  prime  importance.  This  argu- 
ment, however,  should  not,  in  our  opinion,  deter  surgeons 
from  removing  as  many  of  the  regional  glands  as  possible. 
The  great  object  is,  of  course,  to  cure  as  many  patients  as 
possible,  and  if  by  the  systematic  removal  of  these  glands 
a  greater  number  of  women  are  saved,  the  surgeon  should 
not  hold  his  hand  because  the  primary  mortality  is  thereby 
increased. 

Statistics,  as  far  as  they  show  anything,  seem  to  prove 
that  the  removal  of  glands,  when  definitely  carcinomatous, 
is  usually  followed  by  recurrence.  This  has  been  the  ex- 
perience, among  others,  of  Wertheim,  most  of  whose  cases 
died  within  three  years  ;  of  Fromme,  who  states  that 
recurrence  has  occurred  in  all  of  Bumm's  cases  in  1902 
and  1903  in  which  carcinoma  of  the  glands  was  detected; 
and  of  von  Rosthorn,  in  all  of  whose  cases  except  one 
recurrence  had  occurred  where  he  had  removed  carcinoma- 
tous glands.  The  English  records  are  of  too  late  a  date 
to  make  them  of  any  value  for  this  purpose.  Post-mortem 
records  of  patients  dying  as  a  result  of  the  operation  show 
that  in  many  cases  where  carcinomatous  glands  have 
been  removed,  others  which  could  not  be  removed  have 
also  been  affected,  and,  therefore,  that  it  was  useless  to 
remove  any  glands  in  the  first  instance.  Veit,  Pankow,  and 
Wertheim,  among  others,  are  of  opinion  that  the  routine 
extirpation  of  glands  does  not  help  the  case,  and  the  latter 
remarks  that  since  in  only  one-third  of  the  cases  are  the 
glands  involved,  to  remove  them  indiscriminately  in  every 
case  is  to  injure  the  other  two-thirds,  and  that  the  occa- 
sional cure  of  a  patient  does  not  counterbalance  the  extra 
mortality  due  to  routine  extirpation.  The  condition  of  the 
primary  growth  is  no  absolute  guide,  for  while,  as  a  rule, 


WERTHEIM'S   OPERATION  373 

the  glands  are  only  affected  at  a  late  stage,  often  being 
found  quite  free  in  very  advanced  operable  cases,  still 
glands  markedly  enlarged  and  infected  have  been  found 
in  the  earlier  stages  of  carcinoma  of  the  cervix.  The  object 
of  removing  glands  is,  of  course,  to  prevent  recurrence 
therein,  but  recurrence  in  the  glands  only  is  rare.  Schauta 
argues  that  that  only  can  be  considered  a  real  glandular 
recurrence  in  which  there  is  no  local  recurrence,  for  in  the 
latter  condition  it  may  very  well  be  due  to  the  local  state. 
He  remarks  that  facts  have  arisen  which  make  the  spon- 
taneous cure  of  cancer  more  likely.  In  comparing  the 
percentage  of  recurrences  in  the  extended  vaginal  operation 
in  which  the  glands  cannot  be  removed  with  the  radical 
abdominal  operation  in  which  only  local  recurrences  take 
place,  the  difference  is  not  very  material,  and  therefore  a 
question  arises  which  cannot  at  present  be  answered  : 
"  What  becomes  of  the  carcinomatous  glands  always  left 
in  the  case  of  vaginal  operations  and  very  frequently  in 
the  case  of  abdominal  operations  ?  "  After  removal  of  the 
primary  tumour,  carcinomatous  masses  left  behind  in  the 
glands  may  remain  latent  and  only  break  out  very  late, 
and  perhaps  never,  death  being  due  to  other  causes  ;  and 
it  is  noticeable  that,  considering  the  frequency  with  which 
infected  glands  are  found  at  operation,  glandular  recur- 
rence should  be  so  rare.  Hocheisen  had  a  patient  living 
in  1899,  six  and  a  half  years  after  an  incomplete  opera- 
tion, without  any  sign  of  recurrence.  In  35  recurrences, 
Schauta  found  only  2  in  the  glands,  and  in  12  recurrences 
Franz  found  1.  Wertheim,  Zweifel,  Doderlein,  and  others 
only  remove  glands  when  enlarged.  Bumm,  Ries,  Amann, 
von  Rosthorn,  and  Freund  are  in  favour  of  removing 
every  gland  possible,  and  there  are  some  cases  on  record 
which  support  this  practice.  Doderlein  has  2  patients 
living  four  and  a  half  years,  and  3  three  and  a  half  years 
after  the  removal  of  carcinomatous  glands  ;  Wertheim  has  4 
patients  living  three  to  three  and  a  half  years  ;  Mackenrodt, 
1    patient   living   five    years,   3    living   four   years,    and   7 


374  GYNAECOLOGICAL  SURGERY 

living  three  years  ;  whilst  Bumm  has  2  patients  living  three 
years  in  each  case  after  carcinomatous  glands  were  extir- 
pated. 

In  our  opinion  the  importance  of  the  routine  removal 
of  glands  lies  not  so  much  in  the  extirpation  of  those 
obviously  enlarged  as  in  the  prophylactic  excision  of  those 
that  appear  healthy.  Our  experience  is  that  the  glands 
first  affected  are  almost  invariably  those  in  the  parametrium 
and  along  the  external  and  common  iliac  vessels.  The 
removal  of  the  glands  in  these  situations  does  not,  we  have 
found,  materially  add  to  the  length  or  shock  of  the  opera- 
tion, and  we  have,  therefore,  removed  them  in  every  case. 
The  only  method  by  which  the  regional  glands  can  be 
removed  is  through  an  abdominal  incision.  They  cannot 
be  removed  by  paravaginal  section.  The  advocates  of 
paravaginal  section  allow  that  if  all  diseased  glands  could 
be  removed  by  the  abdominal  operation,  this  would  be 
the  best  treatment,  but  maintain  that  as  this  is  impossible, 
there  is  no  need  to  operate  through  the  abdomen,  since 
the  operation  can  be  carried  out  in  every  other  particular 
just  as  well  as  by  the  vaginal  method.  They  contend  that 
just  as  much  parametrium  and  cellular  tissue  can  be 
removed,  with  less  shock,  less  danger  of  infection,  no  scar, 
and  no  greater  danger  of  injury  to  the  ureters,  bladder, 
rectum,  or  large  vessels.  Schauta's  percentage  mortality 
for  258  cases  works  out  at  I0'8,  in  comparison  with 
Wertheim's  15  per  cent,  for  458  cases.  The  mortality  of 
Schauta's  last  45  cases  was  8'5  per  cent.,  of  Wertheim's 
last  30  cases  7  per  cent.  An  analysis  of  Schauta's  cases 
also  shows  the  following  : — 

In  79  early  cases  the  mortality  is  yy  per  cent. 

In    26    moderate    cases    the    mortality   is    n *i    per 
cent. 

In   53    advanced    cases    the    mortality   is    207   per 
cent. 
Paravaginal  section  shows  a  great  advance  in  percentage 
operability    on    simple    vaginal    hysterectomy.       Schauta's 


WERTHEIM'S  OPERATION  375 

percentage  is  487  per  cent.,  which  is  only  slightly  less  than 
that  by  the  abdominal  method.  Lastly,  with  respect  to  the 
question  of  cure,  Schauta's  operation  holds  a  high  position, 
53 "3  per  cent,  of  his  patients  who  were  operated  upon  over 
five  years  ago  being  alive. 

Wertheim  and  others,  on  the  other  hand,  maintain  that 
Schauta's  operation  is  more  difficult,  that  the  primary 
mortality  is  as  great,  that  the  percentage  operability  is  less 
and  the  percentage  of  cures  less,  and  that  the  superiority 
of  the  abdominal  operation  lies  not  only  in  the  opportunity 
it  affords  for  the  removal  of  glands,  but  also  in  the  easier 
removal  of  the  parametric  tissue  and  the  smaller  risk  of 
injury  to  the  bladder,  ureter,  and  intestines,  in  the  more 
reliable  hsemostasis,  and  in  the  great  facility  for  treating 
adhesions. 

Conclusions. — We  ourselves  prefer  the  abdominal  opera- 
tion, the  percentage  operability  of  which  is  undoubtedly 
greater,  whilst  the  mortality  is  probably  about  the  same. 
But  beyond  this  there  are  certain  cases  in  which  the 
vaginal  operation  is  fated  to  fail.  Thus  we  lately  per- 
formed the  radical  abdominal  operation  on  a  patient  with 
an  apparently  early  growth,  whose  obesity  was  such  that 
the  question  of  the  vaginal  operation  had  been  seriously 
considered.  At  the  operation,  in  spite  of  the  fact  that  the 
cervical  growth  was  small  and  the  uterus  very  movable, 
a  carcinomatous  gland  the  size  of  a  walnut  was  found 
on  the  brim  of  the  pelvis.  Had  the  lower  route  been 
chosen,  it  is  obvious  that  the  operation  would  have  been 
better  left  undone. 

Further,  the  abdominal  route  has  these  great  advan- 
tages— that  it  is  possible  to  proceed  a  certain  way  on  the 
operation  and  yet  be  able  to  turn  back  if  satisfactory 
removal  of  the  growth  is  revealed  to  be  impossible ;  whilst, 
on  the  other  hand,  what  appears  from  the  vagina  to  be 
hopeless  fixity  of  the  uterus  may,  when  investigated  from 
the  abdomen,  turn  out  to  be  dependent  on  conditions  not 
cancerous,  the  effective  treatment  of  which  allows  of  the 


376  GYN/ECOLOGICAL  SURGERY 

operation  being  satisfactorily  performed.  Moreover,  it  is 
possible  at  once  to  ascertain  in  many  cases  if  carcinomatous 
involvement  of  the  glands  has  proceeded  so  far  as  to  make 
the  operation  useless. 

As  we  have  stated,  we  systematically  practise  the 
removal  of  the  accessible  regional  glands — namely,  those 
in  the  broad  ligaments,  the  obturator  fossae,  and  along  the 
external  and  common  iliac  arteries — being  of  opinion  that 
the  proceeding  does  not  materially  increase  the  severity  of 
the  operation,  whilst  it  certainly  lessens  the  chances  of 
recurrence.  Even  where  some  of  these  glands  are  car- 
cinomatous and  the  chances  are  against  a  permanent  cure, 
it  is  surely  better  to  free  the  patient  of  gross  evidence  of 
carcinoma  rather  than  perform  an  operation  that  may 
leave  big  masses  of  the  growth  behind. 

Lastly,  in  our  experience,  the  convalescence  from  the 
radical  vaginal  operation  is  much  more  markedly  associated 
with  suppuration,  and  takes  a  much  longer  time. 

There  are,  however,  two  conditions  in  which  we  believe 
that  the  vaginal  route  should  be  chosen :  (i)  in  cases  of 
great  obesity,  especially  in  nulliparae ;  (2)  in  cases  in  which, 
in  addition  to  the  primary  growth  in  the  cervix,  a  meta- 
static nodule  is  present  in  the  lower  inch  of  the  vaginal  wall. 

Limits  of  Wertheim's  operation. — It  is  impossible  in 
many  cases  to  decide  from  vaginal  examination  whether 
the  removal  of  the  growth  is  feasible  or  not. 

The  examination  in  doubtful  cases  must  be  conducted 
under  an  anaesthetic.  Partial  fixity  of  the  uterus  is  no 
contra-indication,  for,  so  long  as  it  can  be  pushed  up,  the 
fact  that  it  cannot  be  pulled  down  is  of  no  moment.  The 
important  point  to  decide  is  the  nature  of  the  fixation. 
Rigidity  of  the  broad  ligaments  appearing  to  be  due  to 
infiltration  is  often  shown  on  opening  the  abdomen  to  be 
caused  by  the  salpingitis  commonly  met  with  in  advanced 
cases.  Considerable  extension  of  the  growth  along  the 
lateral,  and  particularly  the  posterior,  vaginal  wall  is  com- 
patible   with    successful    extirpation.      Infiltration    of    the 


WERTHEIM'S   OPERATION  377 

rectal  wall  contra-indicates  any  operation,  but  this  degree 
of  extension  usually  occurs  so  late  that  the  operation  is 
not  feasible  on  other  counts  as  well. 

Infiltration  of  the  bladder-wall  is  the  most  serious 
drawback  to  the  operation,  and  when  extensive  is  an 
absolute  bar  to  any  attempt  at  removal.  It  is  often  im- 
possible to  be  sure  of  this  until  the  separation  of  the  bladder 
is  commenced,  for  the  uterus  may  be  movable  and  yet 
the  growth  have  involved  the  bladder,  the  conjoined  organs 
moving  up  and  down  together. 

The  slighter  degrees  of  adhesion,  probably  inflammatory, 
may  be  overcome  by  swab-pressure  and  cautious  snipping 
with  scissors,  but  if  this  is  impossible  the  surgeon  has 
the  choice  of  desisting  from  further  attempts  at  removal 
or  of  excising  the  adherent  piece  of  bladder. 

If  the  patient  is  young  and  relatively  strong,  and  the 
area  of  adhesion  is  not  extensive  and  involves  only  one 
uretero-vesical  junction  or  neither,  and  if  there  are  no 
other  bars  to  the  completion  of  the  operation,  the  portion 
of  bladder  should  be  excised,  with,  if  need  be,  the  adherent 
segment  of  ureter  on  that  side.  After  the  extirpation  has 
been  completed  the  hole  in  the  bladder  must  be  closed, 
and  the  ureter,  if  it  has  been  cut,  must  be  implanted  in 
the  vesical  wall. 

If,  however,  the  patient  is  elderly  or  feeble,  and  the 
growth  extensive  elsewhere,  the  operation  should  be  ter- 
minated by  suturing  up  the  raw  surfaces  already  made 
and  closing  the  abdominal  wound.  These  uncompleted 
cases  usually  recover  well. 

If  a  large  mass  is  found  in  the  broad  ligament,  the 
question  of  the  propriety  of  continuing  the  operation  will 
depend  upon  the  relation  to  it  of  the  ureter.  This  structure 
resists  infiltration  for  a  long  time,  and  is  often  found  on 
the  lateral  aspect  of  the  mass,  having  been  pushed  there 
in  front  of  the  growth.  At  other  times  it  runs  in  a  sort 
of  canal  or  groove  through  the  growth,  from  which  it 
can  be   dissected  out. 


37«  GYNAECOLOGICAL  SURGERY 

Though  excision  of  portions  of  the  bladder  or  of  the 
ureter  may  be  successful,  yet  the  likelihood  of  a  fistula  is 
great.  Such  fistulae  cause  great  distress,  and  the  problem 
of  how  to  deal  with  them  is  itself  beset  with  many  diffi- 
culties and  risks.  Further,  the  chance  of  permanent  cure 
in  a  case  so  advanced  is  slight,  while  the  temporary  relief 
to  the  patient  obtained  from  the  removal  of  the  growth 
is  counterbalanced  by  the  annoyance  of  continual  leakage 
of  urine.  Great  judgment  is  therefore  required  before 
deciding  to  proceed  to  these  lengths. 

Preliminary  operation.  —  If  there  is  any  offensive  dis- 
charge, an  anaesthetic  can  be  given  and  the  growth  scraped 
away  as  much  as  possible,  after  which  the  bleeding  surface 
may  be  cauterized  and  the  vagina  washed  twice  daily 
with  a  solution  of  hydrogen  peroxide  (10  volumes)  till 
the  major  operation.  This  preparatory  treatment  has 
certain  disadvantages  :  the  cauterized  cervix,  if  many  days 
elapse  between  the  operations,  sloughs,  and  the  septic 
discharge  is  often  worse  than  that  for  which  the  cauteriza- 
tion was  originally  undertaken ;  the  patient,  again,  is 
subjected  to  the  risks  of  a  double  anaesthetic.  If  this 
practice  is  followed,  the  radical  operation  should  not  be 
undertaken  until  the  cauterized  tissue  has  entirely  sloughed, 
leaving  a  clean  surface. 

If  cauterization  is  decided  on,  we  think  the  best  prac- 
tice is  to  perform  it  immediately  before  undertaking  the 
radical  operation ;  but  latterly  we  have  given  it  up  alto- 
gether, and  contented  ourselves  in  these  cases  with  simple 
scraping  a  week  or  two  beforehand.  If  there  is  no  offensive 
discharge,  preliminary  scraping  is  unnecessary. 

Great  care  should  be  taken  not  to  do  this  preliminary 
scraping  too  thoroughly,  for  (i)  the  tissue  between  the 
growth  and  the  bladder  or  the  pouch  of  Douglas  may  be 
so  thin  that  either  may  be  opened,  and  (2)  so  much  of 
the  cervix  may  be  removed  that  later  in  the  course  of 
the  major  operation  the  body  of  the  uterus  may  tear  away 
from  the   diseased  cervix. 


WERTHEIM'S  OPERATION  379 

Preparation  of  the  patient. — See  pp.  82-86.  As  a  good 
many  of  these  patients  are  in  a  miserable  state  of  health, 
they  should  be  kept  in  hospital  ten  days  or  a  fortnight 
prior  to  the  major  operation,  during  which  time  the  im- 
provement of  their  general  condition  must  be  attempted 
by  good  feeding  and  tonics. 

Immediately  before  the  operation  the  vagina  should  be 
thoroughly  swabbed  out  with  3  per  cent,  formalin,  and 
then  packed  with  sterilized  gauze. 

Instruments. — See  p.  276.  In  addition  four  long 
angular  Kocher's  pressure-forceps,  four  additional  ring 
forceps,  a  Berkeley-Bonney  clamp,  an  aneurysm-needle, 
a  blunt  Worrall's  needle,  and  two  pieces  of  india-rubber 
sheeting,  14  in.  by  12  in.,  will  be  required. 

Operation,  i.  Opening  the  abdominal  cavity. — See 
p.  276.  One  of  the  serious  complications  of  our  earlier 
cases — and  this  has  happened  to  many  other  surgeons — 
consisted  in  sloughing  of  the  abdominal  wound,  due  (1)  to 
the  bruising  of  the  tissues  from  their  prolonged  manipu- 
lation, (2)  to  infection  of  the  tissues  by  some  organism 
from  the  vagina  when  this  canal  was  divided.  To  obviate 
these  dangers  we  cover  the  wound  in  the  abdominal  wall 
with  red  sheet  rubber — having  tried  nearly  every  other 
substance  in  any  way  suitable,  and  found  the  rubber  the 
best.  This  covering  is  kept  in  place  with  the  retractor  (Fig. 
258).  Since  we  have  followed  this  method  not  one  of 
our  wounds  has  sloughed. 

The  abdominal  incision  must  be  a  large  one,  in  all 
cases  extending  to  the  umbilicus,  and  in  fat  patients  at 
least  an  inch  above.   ; 

ii.  Ligaturing  the  ovarian  vessels.— The  ovarian  vessels 
are  ligatured  on  each  side  by  passing  a  No.  4  silk  ligature 
underneath  them  just  where  the  ovarico-pelvic  ligament 
reaches  the  brim  of  the  pelvis,  the  uterus  being  pulled  over  to 
the  opposite  side  by  the  assistant,  so  that  this  ligament  may 
be  put  on  the  stretch  (Fig.  259).  Before  passing  the  ligature 
the  upper  edge  of  the  ligament  should  be  rolled  between 


38o 


GYNECOLOGICAL  SURGERY 


the   index-finger   and    thumb   to   ensure   that   the    ureter, 
which  is  very  superficial  at  this  point,  is  not  included  in  it. 


Fig.  258. — Radical  abdominal  operation  for  carcinoma  of 
the  cervix  :     Preparing  the  abdominal  wound. 

iii.  Clamping  the  ovarico-pelvic  ligament. — The  ovarian 
vessels  at  their  uterine  end  are  clamped  on  each  side 
with    a   pair    of    Kocher's    forceps    applied    to    the    broad 


Fig.  259. — Ligaturing  the  ovarian  vessels. 


WERTHEIM'S  OPERATION 


381 


ligament  close  to  the  uterus.  The  forceps  will  also  include 
part  of  the  round  ligaments. 

iv.  Division  of  the  ovarico-pelvic  ligaments. — The  ovarico- 
pelvic  ligaments  are  divided,  either  with  the  scalpel  or 
scissors,  just  distaily  to  the  ligatures  which  have  been 
placed  on  them  (Fig.  260). 

v.  Ligaturing  the  round  ligaments. — A  ligature  of 
No.  4  silk  is  passed  under  the  round  ligament  on  each  side, 


Fig.  260. — Dividing  the  ovarico-pelvic  ligament. 

and  this  structure  is  tied  as  far  away  from  the  uterus  as 
possible  and  divided  (Fig.  261).  Two  mass  ligatures  are 
now  placed  round  the  separated  appendages  at  their  junc- 
tion with  the  uterus.  The  ends  of  these,  if  left  long,  make 
a  convenient  tractor. 

vi.  Reflecting  the  bladder. — The  peritoneum  on  the 
anterior  surface  of  the  uterus  at  the  upper  limits  of  its 
loose  attachment  is  incised  right  across,  and  together  with 
the  bladder  is  separated  from  the  supravaginal  cervix 
and  the  upper  part  of  the  vagina  by  pushing  it  downwards 
with  a  swab  (Fig.  262).  This  separation  may  be  aided  by 
a  few  gentle  snips  with  the  scissors,  dividing  certain  of  the 


382 


GYNAECOLOGICAL  SURGERY 


Fig.  261. — Ligaturing  the  round  ligament. 


Fig.  262. — Pushing  back  the  bladder. 


WERTHEIM'S   OPERATION  383 

muscle-fibres  of  the  bladder  which  adhere  to  the  vagina 
and  tend  to  tear  back  into  the  bladder  like  a  "  hang-nail  " 
unless  cut  free. 

vii.  Identification  of  the  ureters  and  dissection  of 
their  cervical  portion. — The  ureter  on  each  side  has  now 
to  be  identified.  The  ease  with  which  this  can  be  done 
varies.  In  some  cases  the  ureters  can  be  seen  at  once  and 
dealt   with   quite   easily,   in   others   the   greatest    difficulty 


Fig.  263. — Identifying  the  ureter. 

may  be  experienced  in  finding  them.  The  best  way  is  to 
pull  up  the  posterior  layer  of  the  broad  ligament  with 
pressure-forceps,  and  on  rolling  this  layer  between  the 
finger  and  thumb,  commencing  in  the  region  of  the  ovarian 
ligature,  the  ureter  will  be  felt  as  a  cord  slipping  under 
the  finger,  about  the  size  and  offering  the  resistance  of  a 
quill  toothpick.  Often  it  can  be  seen  through  the  vascular 
subperitoneal  tissue  as  a  white  line.  The  ureter  having 
been  identified,  an  aneurysm-needle  is  pushed  under  it, 
after  which  it  is  traced  forwards  to  where  it  passes  under 
the  uterine  artery   (Fig.  263). 


3§4 


GYNECOLOGICAL  SURGERY 


viii.  Ligaturing  the  uterine  vessels. — -The  uterine  ves- 
sels should  he  ligatured  with  No.  4  silk  as  far  out  towards 
the  wall  of  the  pelvis  as  possible.  This  is  best  done  by 
first  separating  these  structures  from  the  ureter  by  pushing 
the  index  -  finger  through  the  potential  space  (ureteric 
canal)  which  is  present  in  this  neighbourhood  (Fig.  264), 
and,  having  raised  them,  passing  under  them  a  ligature  by 
means   of  Worrall's   needle.     The   division  of  the   uterine 


Fig.  264. — Ligaturing  the  uterine  artery. 

vessels  will  expose  the  ureter,  so  that  it  can  be  easily 
separated  up  to  the  bladder. 

In  cases  where  the  parametrium  is  healthy  the  uterine 
vessels  quickly  come  into  view,  but  in  others  their  identifi- 
cation is  very  troublesome.  If  no  "  ureteric  canal  "  can 
be  found,  the  vessels  should  be  sought  for  and  ligatured 
just  as  they  leave  the  trunk  common  to  them  and  the 
superior  vesical  artery  on  the  side  wall  of  the  pelvis.  It  is 
necessary  to  ligature  the  distal  end  of  the  vessel  after 
dividing  it,  on  account  of  the  free  anastomosis. 

ix.  Separation    of  the    ureters. — By  gently    pulling   on 


WERTHEIM'S   OPERATION 


385 


the  aneurysm-needle  the  ureter  is  raised  from  its  bed  of 
cellular  tissue  in  the  base  of  the  broad  ligament,  and  is 
then  carefully  dissected  free  with  the  points  of  the  dis- 
secting forceps  or  with  a  few  slight  snips  of  the  scissors. 
By  degrees  the  cervical  portion  of  the  ureter  is  freed  up  to 
its  point  of  entrance  into  the  bladder  (Fig.  265).  If  diffi- 
culty is  found  in  tracing  the  ureter  after  the  uterine  artery 


Fig.  265. — Isolating  the  ureter. 


has  been  divided,  it  is  helpful  to  seize  the  distal  end  of  the 
latter  with  forceps  and  gently  pull  it  back  towards  the 
uterus,  when,  as  it  strips,  the  ureter  lying  underneath  it 
comes  into  view.  As  a  rule,  the  left  ureter  is  the  more 
difficult  to  isolate. 

x.  Separating    the     rectum     and     dividing     the     utero- 

sacral    ligaments. — The  uterus  is  pulled  well  forwards  by 

the  assistant,  and  the  peritoneum  at  the  bottom  of  Douglas's 

pouch  is  caught  with  a  pair  of  forceps,  pulled  up  and  snipped 

z 


386 


GYNECOLOGICAL  SURGERY 


(Fig.  266).  The  index  finger  is  then  pushed  through  this 
opening  in  the  peritoneum  and  separates  the  rectum  from 
the  posterior  vaginal  wall  downwards  for  over  an  inch 
(Fig.  267).  The  utero-sacral  folds  are  next  clamped  and 
divided,  care  being  taken  not  to  include  the  ureter  in  the 
forceps,  by  keeping  that  structure  out  of  the  way  with 
the  finger  (Fig.  268). 

The  rectum  may  be  injured  during  its  separation  from 


Fig.   266. — Incising    the 
peritoneum  posteriorly. 

the  posterior  vaginal  wall,  or  may  necrose  later,  in  each 
case  causing  a  recto-vaginal  fistula.  Wertheim,  in  his 
458  cases,  had  one  recto-vaginal  fistula.  We  have  had  one 
case,  and  there  are  two  examples  in  the  291  cases  collected 
by  us. 

xi.  Clamping  and  removing  the  lateral  masses  of  para- 
vaginal tissue. — The  utero-sacral  ligaments  having  been 
divided,  the  mass  of  cellulo-fibrous  tissue  forming  the 
lateral  cervico-pelvic  ligaments  in  the  base  of  the  broad 
ligament,  perhaps  infiltrated  with  growth  or  inflammatory 


WERTHEIM'S   OPERATION 


387 


products,   will  be  found  stretching  out  from   the  side   of 
the  cervix  to  the  wall  of  the  pelvis.    This  mass  is  clamped 


Fig.  267. — Separat- 
ing the  rectum 
from  the  vagina. 

on  each  side  with  angular  Kocher  forceps  as  near  the  pelvic 
wall  as  possible,  and  is  then  divided  with  scissors,  so  that 


Fig.  268. — Dividing  the  utero-sacral  ligament. 


388 


GYNECOLOGICAL  SURGERY 


as  much  as  possible  of  the  cellular  tissue  here  is  removed 
(Fig.  269). 

xii.  Final  separation  of  the  bladder. — The  parts  to 
be  removed  are  now  almost  isolated,  but  before  proceeding 
to  this  step  the  bladder,  especially  in  the  neighbourhood 
of  the  ureters,  is  still  further  pushed  off  the  anterior  vaginal 
wall,  this  step  being  rendered  easier  by  the  facility  with 
which  the  operator  can  pull  up  the  vagina. 


Fig.  269. — Dividing  the  paravaginal  tissue. 


xiii.  Clamping  the  vagina. — The  uterus,  together  with 
the  cellular  tissue  in  its  neighbourhood,  is  now  to  be 
removed  by  cutting  across  the  vagina  as  low  down  as  pos- 
sible. This  is  one  of  the  most  important  steps  of  the  oper- 
ation, and  when  it  is  properly  carried  out  the  diseased 
cervix  is  removed  in  a  bag  of  vagina,  the  vagina  being 
cut  across  at  a  part  where  it  is  presumably  healthy,  so 
that  the  risk  of  cell-implantation  is  absent.  To  achieve 
this,  Wertheim  places  special  clamp-forceps  across  the 
vagina,  above  the  line  of  its  contemplated  division. 

The   application   of  these   forceps   is  not   always   easy. 


WERTHEIM'S   OPERATION 


589 


We  have  tried  several  patterns  after  the  models  of  Wertheim 
and  Howard  Kelly,  but  have  found  all  of  them  inconvenient 
in  difficult  cases  and  more  or  less  liable  to  slip  and  come 
off  at  the  critical  moment  of  amputation.  We  have  there- 
fore devised  a  new  pattern,  for  application  in  the  antero- 
posterior vertical  plane  (Fig.  14,  p.  15).  The  blades  are 
joined  at  a  T-angle  to  shanks  sufficiently  curved  to  embrace 
the  mass  to  be  removed,  and  additional  grip  is  obtained 


Fig.  270. — Adjusting  the  vaginal  clamp. 

by  serrating  them  longitudinally,  and  giving  them  a 
"  spring  "  similar  to  that  characterizing  Doyen's  smaller 
clamp-forceps.  Two  pairs  of  finger  rings  are  provided, 
of  which  the  lower  are  used  for  the  purposes  of  adjustment 
and  the  upper  to  obtain  the  necessary  force  when  clamping. 
We  have  found  this  instrument  superior  in  every  way 
to  the  other  patterns  we  have  used.  It  is  easy  to  apply, 
it  cannot  slip,  and  it  makes  an  excellent  tractor.  The 
uterus  is  pulled  up  out  of  the  pelvis  as  far  as  possible  by 
the   assistant,    and,   the   vagina   having   been   well   cleared 


J  90 


GYN/EGOLOGICAL  SURGERY 


of  the  bladder  in  front  and  the  rectum  behind,  the  gauze 
which  was  inserted  into  the  vagina  just  before  the  operation 
is  removed,  after  which  the  vagina  is  clamped  with  the 
Berkeley-Bonney  forceps  right  across  and  well  below  the 
limits  of  the  growth  (Fig.  270). 


Fig.  271.— Dividing  the 
vagina  by  the    cautery- 
knife. 


xiv.  Division  of  the  vagina. — The  clamp  having  been 
securely  fixed,  and  a  swab  having  been  placed  between 
the  rectum  and  vagina,  this  canal  is  divided  below  the 
clamp  from  left  to  right,  either  with  the  actual  cautery  or 
with  the  scalpel  (Fig.  271).  If  the  former  is  used,  the 
parts  around  must  be  packed  off  with  moist  sterilized 
gauze.  The  anterior  vaginal  wall  should  be  divided  across 
its  whole  breadth  before  the  posterior  wall  is  incised. 


WERTHEIM'S   OPERATION 


59  e 


xv.  Application  of  ligatures. — Immediately  the  removal 
has  been  effected,  ligatures  must  be  applied  for  permanent 
control  of  the  vessels  divided.  The  first  of  these  secure  the 
lateral  vaginal  angle  and  adjacent  paravaginal  tissue  on  each 
side,  from  which  there  is  always  free  bleeding  (Fig.  272). 
Afterwards  the  clamps  upon  the  stumps  of  the  utero-sacral 
ligaments  and  the  subureteric  masses  of  tissue  are  replaced 
by  ligatures,  which  are  most  conveniently  passed  by  means 


Fig.  272. — Ligaturing  the  lateral  vaginal  angle. 


of  Worrall's  blunt  needle.  As  the  operator  is  working  very 
deep,  and  close  up  to  the  side  wall  of  the  pelvis,  this  is  often 
a  troublesome  part  of  the  operation.  The  needle  should 
be  passed  deeply  to  the  point  of  the  clamp,  and  the 
ligature  tied  behind  the  clamp. 

xvi.  Further  removal  of  cellular  tissue  and  the  regional 
glands. — All  bleeding  having  been  stopped,  the  surgeon 
explores  for  lymphatic  glands  still  remaining  on  the  side- 
wall  of  the  pelvis.  It  is  important  to  obtain  access  to  the 
obturator  fossae,  and  this  is  effected  by  isolating  a  sheet  of 
tissue  containing  at  its  upper  edge  the  common  trunk  of  the 
uterine  and  superior  vesical  arteries  and  its  continuation, 


392 


GYNAECOLOGICAL  SURGERY 


the  superior  vesical  and  obliterated  hypogastric  arteries. 
This  sheet,  having  been  isolated  by  the  finger,  is  ligatured 
at  its  distal  end,  divided,  and  stripped  back  as  far  as  the 
internal  iliac  artery,  where  it  is  again  ligatured  and  removed. 
The  obturator  region  is  now  exposed  with  the  artery  and 
nerve,  and  the  glands  and  loose  cellular  tissue  are  removed 
therefrom. 

The  peritoneum  is  next   stripped  off  the  external  and 


Fig.   273. — Removing  the  iliac  glands. 


common  iliac  arteries  by  the  finger,  and  the  chain  of  glands 
lying  between  the  artery  and  vein  is  separated  by  ring 
forceps  at  its  lower  end,  and  stripped  upwards  (if  possible, 
as  a  continuous  piece  of  tissue)  to  near  the  bifurcation  of 
the  aorta,  where  a  ligature  is  applied  to  it,  and  it  is  then 
removed  (Fig.  273). 

Glands  are  sometimes  found  adherent  to  the  iliac  vein, 
in  which  case  great  care  must  be  taken  when  removing 
them  not  to  injure  it.  If  the  vein  is  torn,  it  would,  of 
course,  have  to  be  ligatured,  laterally  if  possible. 

xvii.  Suturing  the  pelvic  peritoneum. — All  serious  bleed- 


WERTHEIM'S   OPERATION 


393 


ing  having  been  arrested  by  further  ligatures,  and  oozing 
by  hot  swabs  if  necessary,  the  anterior  peritoneal  flap  is 
sutured  to  the  cut  edge  of  the  posterior  peritoneum  covering 
the  back  of  the  pelvis,  with  a  continuous  suture  of  No.  4  silk 
from  left  to  right,  so  that  in  this  manner  the  peritoneum 
covering  the  bladder  is  sutured  to  that  on  the  anterior 
face  of  the  rectum,  and  eventually  the  floor  of  the  pelvis 


Fig.  274. — Suturing  the  peritoneal  flaps. 


is  covered  over  and  the  raw-surfaced  cavity  of  the  pelvis 
disappears  from  view  (Fig.  274). 

The  suturing  should  be  commenced  at  the  region  of  the 
left  ovarian  ligature  and  carried  across  to  a  similar  point 
on  the  right.  Any  little  holes  in  the  line  of  the  peritoneal 
suture  are  closed  by  interrupted  sutures  so  that  the  saline 
fluid,  if  subsequently  to  be  introduced,  is  prevented  from 
escaping. 

xviii.  Closing  the  abdominal  cavity. — See  p.  285.  Be- 
fore closing  the  abdomen,  three  pints  of  saline  solution 
at  a  temperature  of  1080  F.  may  be  poured  into  the  abdo- 
minal cavity  to  prevent  shock. 

Difficulties  and  dangers,  i.  Separation  of  the  bladder. 
— The  ease  with  which  the  bladder  can  be  separated  depends 


394  GYNAECOLOGICAL  SURGERY 

entirely  on  the  extent  of  the  growth.  In  an  early  case 
the  bladder  strips  quite  easily  and  the  fibres  of  the  vagina 
at  once  come  into  view,  and  the  separation  is  carried  down 
till  the  upper  inch  of  the  anterior  vaginal  wall  is  exposed. 
On  the  other  hand,  if  the  growth  is  extensive,  very  great 
difficulty  may  be  experienced  in  separating  the  bladder, 
and  this  viscus,  unless  the  greatest  care  be  taken,  is  very 
likely  to  be  injured.  The  risk  is,  of  course,  all  the  greater 
if  the  bladder  itself  is  found  to  be  infiltrated ;  in  that 
case,  indeed,  it  becomes  a  question  whether  the  opera- 
tion should  be  persevered  with,  since  it  may  be  neces- 
sary to  excise  that  portion  of  the  bladder  which  is  affected. 

If  the  wound  remains  undiscovered,  or  after  suture 
does  not  heal,  a  fistula  of  course  results,  as  it  may  after 
the  bladder  has  been  opened  deliberately  and  a  piece  of 
it  resected.  Vesico  -  vaginal  fistula  may  also  be  due  to 
necrosis  of  the  bladder -wall  from  sepsis  and  sloughing 
aided  by  its  diminished  blood-supply,  owing  to  ligature 
of  the  vesical  arteries  or  denudation  of  its  walls  when 
separating  it  from  the  vagina.  We  have  no  records 
of  Wertheim's  for  vesico-vaginal  fistula.  Bumm,  in  his 
108  cases,  injured  the  bladder  5  times  ;  2  of  the  wounds 
healed  with  fistula,  3  of  the  patients  died.  We  have  had 
3  cases,  and  the  accident  occurred  15  times  in  the  291 
British  cases  collected  by  us  ;  in  13  of  these  the  wound 
closed  spontaneously,  and  in  2  the  fistula  was  closed  by 
operation.  On  4  occasions  in  the  same  series  the  bladder 
was  intentionally  opened,  and  in  each  case  the  wound 
healed  without  a  fistula,  portions  of  the  bladder  being 
removed  in  3  cases.  At  the  Johns  Hopkins  Hospital,  in 
157  cases  the  bladder  was  injured  19  times  =  12 'i  per 
cent.  Schindler  ha>  collected  362  cases  (nine  operators) 
with  the  bladder  and  ureter  wounded  90  times  =  24/8 
per  cent. 

In  comparison  with  this,  Schauta  wounded  the 
bladder  11  times  (7  accidental  injuries,  4  fistulae)  ;  and 
Doderlein  collected   1,979   cases    (90    operators)    of    simple 


WERTHEIM'S   OPERATION  395 

vaginal  hysterectomy,  and  found  the  bladder  wounded 
61  times ;  whilst  Olshausen  had  638  cases  with  the 
bladder  wounded  22  times.  In  all  of  Wertheim's  cases 
where  a  portion  of  the  bladder  or  ureter  has  been  inten- 
tionally resected,   recurrence  has  been  early. 

If  the  bladder  has  been  accidentally  injured,  or  a  piece 
of  it  purposely  resected,  it  is  often  a  very  difficult  and 
lengthy  procedure  to  suture  the  opening  properly,  situated 
as  it  is  at  the  junction  of  the  posterior  wall  and  trigone. 
Sepsis,  too,  frequently  occurs  in  this  situation,  and  after 
operation  the  sutures  are  less  likely  to  hold.  Russell 
Andrews  tells  us  that  in  three  cases  he  very  successfully 
and  rapidly  repaired  the  wound,  after  he  had  intentionally 
resected  a  portion  of  the  bladder  for  growth,  by  suturing 
the  anterior  vaginal  wall  over  the  opening. 

During  the  separation  of  the  bladder  there  may  be 
troublesome  bleeding  from  the  anterior  vaginal  vessels. 
These,  if  possible,  should  be  secured  with  forceps  and  tied, 
or,  failing  this,  the  oozing  must  be  temporarily  arrested 
by  pressure  with  a  swab. 

ii.  Injury  to  the  ureters. — One  of  the  principal  points 
to  remember  is  not  to  free  more  ureter  than  is  necessary, 
and  to  be  most  careful  not  to  injure  the  peri-ureteral  plexus 
of  vessels,  since  if  this  is  done  there  is  danger  of  the  ureter 
subsequently  necrosing. 

From  what  has  been  said,  it  will  be  apparent  that  the 
chief  danger  of  this  operation  is  injury  to  the  ureters. 
They  run  the  risk  of  injury — 

(1)  When  the  ovarian  ligatures  are  being  applied. 

(2)  When  the  uterine  vessels  are  being  tied. 

(3)  When  their  cervical  portion  is  being  dissected  free. 

(4)  When  the  vaginal  clamp  is  being  applied. 

(5)  WThen  the  pelvic  peritoneum  is  being  sutured. 
The    injury   may   consist   in    dividing    them,    including 

them  in  a  ligature  or  suture,  damaging  the  peri-ureteral 
plexus  of  vessels  (stripping  them  too  clean),  or  crushing 
them  with  forceps. 


396  GYNECOLOGICAL  SURGERY 

If  they  are  divided,  it  is  necessary  to  determine  which 
is  the  best  treatment.  The  divided  ends  can  be  sutured 
by  the  method  described  on  p.  544,  but  it  is  best  if  possible 
to  implant  the  renal  end  into  the  bladder  (p.  540).  The  renal 
end  can  also  be  ligatured  in  the  hope  that  the  kidney  may 
atrophy  ;  if  it  does  not,  this  organ  will  have  to  be  removed 
at  a  future  date.  If  the  accident  is  not  discovered  and 
treated,  or  if  the  ureter  necroses  after  it  has  been  sutured 
or  implanted,  the  urine  will  escape  through  the  vagina  and, 
if  the  patient  lives,  a  permanent  fistula  results.  This  will 
have  to  be  dealt  with  at  a  later  date  by  transplanting  the 
end  into  the  bladder  or  removing  the  kidney.  In  the 
latter  event,  great  care  must  be  taken  not  to  remove 
the  wrong  kidney. 

These  accidents  are  more  likely  to  happen  when  the 
growth  is  an  extensive  one  and  when  infiltration  has  taken 
place  into  the  broad  ligament,  so  that  the  mass  forms  a 
great  buttress  on  each  side.  At  times,  when  the  ureter  is 
surrounded  by  much  infiltration,  it  can  be  dissected  out 
only  with  the  greatest  difficulty,  or  this  may  be  found 
altogether  impossible,  and  the  involved  portion  will  have 
to  be  resected.  Sometimes,  owing  to  the  ureter  apparently 
lying  at  a  much  lower  level  than  usual,  great  difficulty  will 
be  experienced  in  detecting  it  as  it  winds  round  the  cervix, 
in  which  case  its  dissection  will  have  to  be  commenced 
much  farther  back,  perhaps  even  near  the  ovarian  ligature, 
so  that  when  it  is  freed  it  will  hang  like  a  clothes-line  across 
the  pelvis.  This  method  of  dealing  with  the  ureter  is  to 
be  particularly  avoided  if  possible,  because  of  the  injury 
to  its  blood-supply,  which  is  largely  derived  from  the 
vessels  of  the  peritoneum  to  which  it  is  adherent.  The 
uterine  artery  may  be  found  running  parallel  with  the 
course  of  the  ureter  and  above  it  ;  this  distribution  is 
abnormal,  and  the  vessel  may  be  mistaken  at  first  for  the 
ureter. 

When  the  posterior  layer  of  peritoneum  in  the  neigh- 
bourhood of  the  ovarian  vessels  is  pulled  up  to  pass  the 


WERTHEIM'S  OPERATION  397 

first  stitch  of  the  continuous  suture,  the  ureter  may  be 
pulled  up  with  it,  and  care  must  be  taken  not  to  include 
this  structure. 

iii.  Clamping  and  dividing  the  vagina. — Great  care 
must  be  taken  when  applying  the  clamp  not  to  include  the 
ureter  or  any  portion  of  the  bladder  in  its  grip.  Also, 
when  the  vagina  is  cut  across,  any  discharge  from  it  may 
escape  into  the  peritoneal  cavity.  It  is  for  this  reason 
that  the  preliminary  scraping  and  disinfection  is  so  im- 
portant. The  danger  of  soiling  the  peritoneum  is  over- 
come to  a  certain  extent  by  packing  the  vagina  lightly  with 
gauze  just  before  the  operation  is  commenced,  and  remov- 
ing it  just  before  the  amputation,  as  previously  described. 

Great  care  must  be  taken  also  when  dividing  the  vagina 
not  to  injure  the  ureters,  bladder,  or  rectum.  The  rectum 
is  particularly  in  danger  as  it  is  out  of  sight,  and  for  this 
reason  a  swab  should  be  placed  between  it  and  vagina 
before  the  latter  is  divided. 

Bumm  objects  to  the  use  of  a  clamp,  on  the  ground 
just  stated,  and  also — and  this  he  considers  the  more 
important  reason — because  he  finds  that  its  application 
prevents  the  perfect  removal  of  the  parametrium.  Bumm 
argues  that  the  parametrium  and  cellular  tissue  can  only 
be  properly  separated  when  the  vagina  is  cut  through 
before  the  separation  commences.  For  this  purpose  he 
packs  a  swab  close  up  against  the  cervical  growth  and 
then  separates  the  vagina  well  below  this  at  the  junction 
of  its  middle  and  lower  third.  The  "  cuff  "  that  is  thus 
fashioned  is  sewn  together  over  the  swab,  and  the  rest 
of  the  vaginal  wall  is  thoroughly  disinfected.  This  takes 
ten  minutes.  A  new  set  of  gloves  and  instruments  having 
been  obtained,  the  patient  is  placed  in  the  Trendelenburg 
position  and  the  operation  continued  per  abdomen.  After 
the  ureter  has  been  separated  and  the  uterine  artery  liga- 
tured, the  rectum  is  separated  from  the  posterior  vaginal 
wall  till  the  cut  end  of  the  vagina  is  reached.  The  hand 
then  pulls  up  the  growth  encased  in  the  bag  of  vagina,  and 


39§  GYNECOLOGICAL  SURGERY 

gradually  the  uterus,  parametrium,  and  cellular  tissue  are 
separated  from  below  upwards  and  outwards  as  far  as  the 
lateral  wall  of  the  pelvis,  in  one  piece.  We  have  tried  this 
technique,  but  think  it  inferior  to  that  we  have  described. 

iv.  Arrest  of  haemorrhage. — In  the  course  of  the  opera- 
tion it  may  be  necessary  at  frequent  intervals  to  arrest 
oozing,  or  even  brisk  haemorrhage,  by  means  of  clamp 
forceps  or  ligature.  If  the  bleeding  vessel  is  plainly  seen, 
it  can,  of  course,  be  picked  up  with  forceps  and  ligatured, 
but  much  trouble  is  experienced  from  venous  oozing  due 
to  the  wounding  of  the  plexus  of  veins  in  the  base  of  the 
broad  ligament.  The  bleeding  is  at  times  so  free  that 
the  pelvis  rapidly  fills  up  with  blood.  The  excess  of  blood 
must  be  removed  quickly  with  swabs,  a  clean  swab  pressed 
down  on  the  bleeding  area  by  an  assistant,  and  then  at  a 
given  signal  he  removes  the  swab  and  the  operator  clamps 
the  bleeding  spot.  By  far  the  best  instruments  to  use  for 
this  purpose  are  ring  forceps  (Fig.  5,  p.  10),  which  secure  a 
good  grip  of  the  tissue,  while  their  oval  ends  enable  a  ligature 
to  be  applied  over  them  with  ease  even  in  a  deep  cavity. 
With  the  ureters  separated  and  in  view,  no  fear  need  be 
felt  in  applying  the  forceps,  as  there  are  no  structures  of 
vital  importance  which  can  be  injured.  If  the  bleeding 
is  not  very  brisk,  and  its  source  is  difficult  to  locate,  pressure 
with  a  swab  will  at  times  check  it. 

During  the  dissection  of  the  cellular  tissue  and  removal 
of  the  uterus  the  large  iliac  vessels  will  be  in  view,  and 
injury  to  them  must  be  avoided. 

There  is  usually  a  certain  amount  of  free  haemorrhage 
from  the  cut  vaginal  walls.  This  stops  when  a  mattress- 
suture  is  applied  to  each  lateral  angle  of  the  cut  surface 
(Fig.  272). 

Dressing  and  after-treatment. — The  general  lines  of 
after-treatment  are  indicated  at  p.  44  and  in  Chapter  xxxn. 
Paresis  of  the  bladder  invariably  follows  this  operation,  and 
regular  catheterization  is  a  necessity  for  some  week  or  two 
afterwards.     The   power   of  micturition   always   returns. 


WERTHEIM'S   OPERATION  399 

Postoperative  complications. — There  are  certain  com- 
plications so  frequently  following  this  operation  that  they 
require  a  separate  discussion. 

i.  Shock. — The  shock  is  always  considerable,  and  some- 
times profound.  This  is  due  to  the  time  occupied  by  the 
operation,  the  free  loss  of  blood,  and  the  extensive  dis- 
turbance of  the  parts.  Further,  in  most  cases  the  patient's 
health  is  already  undermined  by  pain,  haemorrhage,  and 
septic  discharges,  in  addition  to  which  many  of  the  women 
are  over  fifty.  The  value  of  time  in  this  operation  cannot 
be  over-estimated.  Up  to  an  hour  and  a  half  the  patients 
stand  the  manipulations  well,  but  after  this  period  every 
ten  minutes  increases  the  amount  of  shock  very  materially. 
A  perusal  of  our  personal  cases  shows  that  the  time  taken 
by  the  operation  in  our  hands  varied  from  51  to 
as  much  as  165  minutes.  These  figures  show  the  strik- 
ing variation  in  the  difficulty  of  the  operation  in  different 
cases,  a  factor  which  is  beyond  the  control  of  the  operator. 
The  difficulties  become  enormously  enhanced  when  the 
patients  are  fat,  or  when  there  is  extensive  infiltration  of 
the  cellular  tissue  or  adhesion  to  the  bladder.  We  have 
found  that  cases  presenting  extensive  infiltration  and 
cancerous  hypertrophy  of  the  cervix  without  ulceration  are 
very  much  more  arduous  to  deal  with  than  those  exhibiting 
excavation  or  fungosis.  In  particular,  the  surgeon  should 
try  to  avoid  injury  to  the  bladder,  for  the  extra  time  taken 
to  suture  the  rent  is  a  great  handicap  to  the  patient.  In 
many  advanced  cases  a  condition  of  chronic  adhesive  sal- 
pingitis is  present  which  delays  the  operation  and  makes 
the  exposure  of  the  ureters  more  difficult.  The  amount  of 
oozing  from  the  extensive  raw  surface  left  after  the  extirpa- 
tion varies  greatly.  In  some  cases,  particularly  in  early 
ones,  it  is  comparatively  slight,  but  where  the  growth  is 
extensive  it  may  be  considerable,  and  time  is  unavoidably 
lost  in   arresting  it. 

Shock  is  lessened  in  these  cases  by  the  routine  intro- 
duction into  the  abdominal  cavity  of  three  pints  of  saline 


400  GYNECOLOGICAL  SURGERY 

infusion  at  a  temperature  of  1080  F.,  and  special  care  should 
be  taken  to  keep  the  patient  as  warm  as  possible. 

ii.  Haemorrhage. — Even  with  the  greatest  care  the 
operator  can  exercise,  a  very  considerable  amount  of  blood 
is  always  lost,  most  of  it  from  a  continual  oozing  which 
it  is  impossible  to  control.  The  operator  should  secure 
every  vessel  that  is  bleeding  even  at  the  commencement 
of  the  operation,  since  it  may  truly  be  said  that  every 
drop  is  of  value. 

Some  operators  have  deliberately  ligatured  both  internal 
iliac  arteries  as  a  preliminary  to  removing  the  uterus. 
The  dangers  of  such  a  proceeding  are  obvious,  and  we  do 
not  think  well  of  it.  Temporary  clamping  of  these  arteries 
has  also  been  suggested,  but  we  have  found  that,  in  those 
cases  in  which  it  is  most  necessary,  a  sufficient  exposure 
of  both  internal  iliac  arteries  is  an  operation  involving 
some  time  and  may  in  itself  cause  a  good  deal  of  bleeding. 

iii.  Septic  infection  of  the  operation  area.  The  bac- 
teriology of  Wertheim's  operation. — The  value  of  syste- 
matic bacteriological  examinations  in  cases  of  carcinoma 
of  the  cervix,  both  before  and  during  the  operation,  is 
insisted  upon  by  Liepmann  from  Bumm's  clinic  in  Berlin. 
His  procedure  is  as  follows  : — 

Three  long-handled  sterile  swabs  are  taken  and  inocu- 
lated— (i)  from  the  carcinomatous  ulcer  exposed  by  Doyen's 
specula  as  soon  as  the  external  genitals  have  been  disin- 
fected ;  (2)  from  the  peritoneal  cavity  as  soon  as  it  is 
opened  ;  (3)  from  the  interior  of  the  growth,  the  glands, 
or  parametrial  tissue — the  surface  of  the  masses  being 
first  sterilized  by  a  glowing  knife,  and  the  tissues  being 
incised  by  a  sterile  knife.  The  three  swabs  are  each  placed 
in  a  sterile  Petri  dish  as  soon  as  they  are  taken,  and  trans- 
ferred to  the  laboratory,  where  the  bouillon  tubes  are 
inoculated. 

Liepmann  thus  gets  his  "  three-swab  "  test.  The  first 
gives  the  primary  bacterial  content  of  the  carcinoma,  the 
second  that  of  the  peritoneal  cavity,  and  the  third  that  of 


WERTHEIM'S  OPERATION 


401 


the  parametrium  and  glands.  In  only  one  of  more  than 
a  hundred  cases  had  complete  sterility  been  procured 
throughout.  In  this  case  the  operation  lasted  130  minutes, 
the  carcinoma  was  broken  into  during  the  separation 
of  the  bladder,  and  the  peritoneum  was  closed  without 
drainage.  Nevertheless  recovery  was  non-febrile  and 
uninterrupted,  and  the  patient  passed  flatus  on  the 
first  day,  showing  absence  of  intestinal  paralysis.  In 
all  other  cases  streptococci  have  been  found,  either 
in  pure  culture,  or  along  with  staphylococci  and  bacilli. 
Streptococci  from  carcinoma  possess  an  extremely  high 
virulence,  especially  for  the  peritoneum.  Where  strepto- 
cocci were  found  in  the  peritoneal  cavity  and  drainage 
was  not  employed,  the  fate  of  the  patients  was,  with  few 
exceptions,  sealed.  Thus,  in  one  case  where  the  opera- 
tion was  easy  and  short,  lasting  only  83  minutes,  where 
streptococci  in  long  chains  were  found  in  the  carcinoma 
and  in  the  peritoneal  cavity,  the  patient  died  from  septic 
infection  on  the  fourth  day.  Influenced  by  Liepmann's 
bacteriological  findings,  Bumm  proceeded  to  leave  the 
peritoneum  open  and  to  employ  drainage  from  below,  with 
the  following  results  : — ■ 


No.  of 

No.  of 

cases 

No.  of 

deaths  from 

operated 

deaths. 

septic 

upon. 

infection. 

Prior  to   July,    1907    (peritoneum 

closed).  . 

34 

16  =  47% 

12  =  38% 

Since     July,     1907     (peritoneum 

open,   drainage  from  below) 

40 

6  =  15% 

2=   5% 

Liepmann  believes  that  it  is  not  the  magnitude  of  the 
operative  procedures  which  accounts  for  the  high  mortality 
of  Wertheim's  operations,  but  that  this  is  due  to  operating 
in  a  bacteria-laden  medium,  i.e.  to  sepsis.  As  a  precaution 
against  sepsis  we  advise  that  the  sound  be  passed  into 
the  uterus  before  the  operation,  in  case  a  pyometra  is 
present.     This  condition  is  a  very  serious  complication,  as, 


2  A 


402  GYNAECOLOGICAL  SURGERY 

during  the  operation,  pus  may  escape  through  the  holes 
made  by  the  volsella  or  in  some  other  way.  We  have  had 
two  cases  of  pyometra,  and  in  291  cases  we  have  collected 
there   are   7  examples. 

As  a  further  precaution  against  sepsis,  the  vagina 
may  be  swabbed  out  with  perchloride  of  mercury, 
1 — 2,000,  after  the  clamp  has  been  applied  and  the  gauze 
packing  withdrawn  ;  but  before  the  vagina  is  divided,  and 
during  the  section  of  the  vagina,  the  surrounding  pelvic 
tissues  should  be  well  protected  by  swabs. 

In  cases  in  which  the  growth  is  not  breaking  down, 
and  the  patients  are  free  from  offensive  vaginal  discharge, 
the  risk  of  serious  septic  infection  of  the  operation  area 
should  be  slight.  A  certain  amount  of  infection  of  the 
extensive  raw  surface  that  is  left  in  the  pelvis  is  perhaps 
inevitable,  and  most  cases  manifest  some  fever  accom- 
panied by  a  vaginal  discharge  during  the  second  week  of 
convalescence.  When  the  cervix  is  extensively  ulcerated, 
or  when  a  fungating  and  stinking  mass  fills  the  vaginal 
vault,  the  probability  of  serious  infection  of  the  operation 
area  becomes  much  enhanced. 

The  methods  taken  for  the  preliminary  cleansing  of 
the  cervix  have  been  already  indicated,  but  in  some  cases 
it  is  impossible  to  ensure  the  discharge  being  absolutely 
sweet.  In  these  cases  signs  of  marked  septic  infection  of 
the  operation  area  usually  begin  about  the  fifth  day  with 
considerable  fever  and  a  foul  discharge  lasting  perhaps 
for  several  weeks. 

iv.  Septic  infection  of  the  bladder. — As  has  been  said,  for 
a  week  or  two  the  patients  suffer  from  inability  to  empty  the 
bladder  completely,  and  this  is  sufficient  in  itself  to  account 
for  the  tendency  that  exists  to  cystitis.  The  tendency  is  in- 
creased by  the  extensive  denudation  of  the  outer  wall  of  the 
bladder  in  the  region  where  it  has  been  separated  from  the 
supravaginal  cervix,  vagina,  and  parametric  tissue,  and  by 
the  injury  done  to  the  bladder-wall  from  its  diminished 
blood-supply  and  from  damage  to  its  nerves.     In  regard  to 


WERTHEIM'S  OPERATION  403 

this,  we  have  pointed  out  that  the  area  of  bladder  attach- 
ment to  the  cervix,  normally  about  f  in.,  becomes  greatly 
elongated  owing  to  the  enlargement  of  the  cervix  produced 
by  the  carcinoma.  In  addition,  this  raw  area  of  the  outer 
bladder-wall  directly  bounds  the  large  subperitoneal  cavity 
left  by  the  operation,  a  cavity  that  in  all  cases  subsequently 
becomes  more  or  less  infected.  The  appearance  of  pus 
in  the  urine  in  these  circumstances  is  not  surprising. 

Wertheim  states  that  cystitis  occurred  in  practically  all 
his  patients,  and  was  one  of  the  principal  causes  of  their 
prolonged  convalescence.  In  some  instances  the  infection 
spread,  causing  pyelo-nephritis,  in  one  case  with  fatal 
results.  In  the  cases  we  have  collected  there  is  a  great 
difference  in  the  frequency  with  which  this  complication 
is  noted  by  the  different  operators,  due,  we  think,  to  the 
care,  or  otherwise,  with  which  the  urine  has  been  tested. 
We  have  had  the  urine  tested  repeatedly  in  all  our  cases, 
and  the  case  was  noted  as  one  of  cystitis  when  any  pus 
was  detected.  We  had  this  complication  in  the  larger 
proportion  of  our  patients.  The  bladder,  therefore,  should 
be  catheterized  twice  a  day  and  washed  out  with  a  solu- 
tion of  boric  acid.  If  this  routine  be  carried  out,  cystitis 
will  not  occur,  or,  occurring,  will  be  of  short  duration. 

v.  Septic  infection  of  the  abdominal  wound. — One  of  the 
most  notable  things  about  convalescence  from  Wertheim's 
operation  is  the  comparatively  large  number  of  cases  in 
which  the  wound  fails  to  heal  by  primary  intention.  There 
may  be  a  stitch-abscess,  a  little  local  suppuration,  or 
sloughing  of  the  whole  wound.  This  latter  is  a  very  tire- 
some complication.  We  have  noted  that  it  has  nearly 
always  occurred  in  those  cases  in  which  the  odour  of  the 
primary  growth  was  markedly  offensive.  It  is  due  to  infec- 
tion, by  an  organism  from  the  site  of  the  primary  growth, 
of  the  tissues  whose  power  of  resistance  has  already  been 
lowered  by  the  bruising  caused  by  prolonged  retraction 
of  the  wound-edges  ;  the  slough  has  the  same  odour  and 
appearance  as  the  sloughing  carcinoma.     Owing  to  the  long 


404  GYNECOLOGICAL  SURGERY 

duration  of  the  operation  in  some  cases,  and  the  degree 
of  manipulation  involved,  the  edges  of  the  abdominal 
wound  may  become  bruised  and  devitalized.  There  is, 
therefore,  a  great  probability  of  sloughing  or  suppuration 
if  during  the  operation  they  become  infected  by  septic 
organisms.  Where  the  cervical  growth  is  breaking  down 
and  stinking,  and  complete  cleansing  by  scraping,  cauteriza- 
tion, and  antiseptic  applications  is  not  possible,  the  abdo- 
minal wound  may  easily  be  infected  by  the  vaginal  contents 
after  the  amputation.  In  several  of  our  cases  this  accident 
appears  to  have  happened.  In  each  of  them,  on  the  fourth 
day  after  the  operation,  when  the  Michel's  clips  holding 
the  skin-edges  together  were  removed,  a  foul  discharge 
was  noticed  oozing  from  the  lower  end  of  the  wound.  The 
skin-edges  were  immediately  separated  along  its  whole 
length,  and  the  cellular  tissue,  fascia,  and  muscle-edges 
were  found  in  a  condition  of  sphacelus.  In  spite  of  this, 
the  skin  itself  was  not  even  reddened,  nor  was  the  patient's 
general  condition  apparently  affected.  Dressings  soaked 
in  peroxide  of  hydrogen  were  immediately  applied,  and  in 
twenty-four  hours  the  wounds  had  a  clean  appearance. 
In  one  case,  a  bacteriological  sample  was  submitted  to 
Messrs.  Foulerton  and  Hillier,  and  an  anaerobic  organism 
was  isolated,  but  the  causal  relation  borne  by  it  to  the 
condition  described  has  to  be  further  investigated.  From 
the  facts  that  the  slough  had  in  all  the  cases  exactly  the 
same  appearance  and  odour  as  that  characterizing  the 
breaking-down  carcinoma,  and  that  the  free  opening  of 
the  wound  to  the  air  and  the  application  of  peroxide  of 
hydrogen  immediately  restored  a  healthy  condition,  it 
would  appear  almost  certain  that  this  peculiar  occurrence 
is  due  to  infection  by  organisms  (probably  anaerobic) 
that  pre-existed  at  the  site  of  the  carcinoma. 

The  prevention  of  wound  infection  is  therefore  an 
important  matter.     It  is  to  be  effected — 

i.  By  procuring  as  complete  a  cleansing  of  the  cervix 
and  vagina  as  the  case  will  admit  of. 


WERTHEIM'S  OPERATION  405 

2.  By  shortening  the  operation  as  much  as  possible, 
and  so  saving  the  wound-edges  from  needless  exposure  and 
manipulation. 

3.  By  covering  those  edges  with  a  layer  of  sterile 
india-rubber  in  the  manner  previously  described  (p.  379). 
Less  manipulation  of  the  wound-edges  is  required  if  a 
mechanical  retractor  be  used.  The  presence  of  wound- 
sepsis  should  be  looked  for  on  the  fourth  day,  when  the 
Michel's  clips  are  removed,  and,  if  there  is  any  oozing  from 
the  lower  end  of  the  wound,  the  skin-edges  there  should 
be  immediately  separated  and  the  condition  of  the  deeper 
parts  investigated.  For  it  is  a  noteworthy  fact  that  the 
skin  may  be  apparently  normal  and  the  wound-edges  well 
united  and  yet  the  cellular  tissue,  fascia,  and  muscular 
edges  under  them  be  in  a  condition  of  sphacelus. 

Sloughing  or  suppuration  having  been  found,  the  whole 
length  of  the  skin-incision  should  be  opened  up  and  dressings 
soaked  with  peroxide  of  hydrogen  solution  (10  volumes) 
freely  applied. 

This  measure  and  the  free  access  of  air  to  the  affected 
part  cause  the  condition  rapidly  to  improve,  and  in  forty- 
eight  hours  the  wound  may  look  quite  clean.  It  will, 
however,  take  many  weeks  to  heal  entirely,  and,  as  a  weak 
scar  is  certain  to  result,  the  patient  must  be  fitted  with 
an  abdominal  belt. 


CHAPTER    XVIII 

THE    OPERATIONS    FOR    BROAD-LIGAMENT 
MYOMATA 

General  remarks. — Broad-ligament  myomata  are  divisible 
into  two  classes.  The  first  variety  is  the  true  ligament 
myoma,  and  springs  from  the  muscle-fibres  normally  found 
in  the  mesometrium.  These  tumours  may,  therefore,  be 
found  in  at  least  three  situations  : 
i.  In  the  round  ligament. 

2.  In  the  ovarico-uterine  ligament. 

3.  In  the  connective  tissue  surrounding  the  ovarian  or 

uterine  vessels. 

As  a  rule,  tumours  growing  in  the  first  two  situations 
are  of  small  size,  and  can  be  enucleated  on  ordinary  prin- 
ciples. Tumours  growing  in  the  third  situation  frequently 
attain  a  large  size ;  they  distend  the  broad  ligament  so 
that  the  Fallopian  tube  is  stretched  and  lies  sessile  on 
their  upper  surface  as  in  a  broad-ligament  cyst.  Having 
exhausted  the  capacity  of  the  broad  ligament,  the  tumour 
pushes  its  way  upwards,  stripping  the  peritoneum  off  the 
lateral  wall  of  the  pelvis  and  iliac  fossa,  and  on  the  left 
side  often  in  addition  burrows  between  the  layers  of 
the  sigmoid  mesocolon,  the  bowel  itself  then  lying  sessile 
upon  the  tumour.  If  the  operator  is  not  familiar  with  the 
anatomy  of  these  tumours  he  may  believe  that  this  condition 
of  the  bowel  is  due  to  adhesions,  and  may  abandon  the 
attempt  to  remove  the  tumour,  when,  as  a  matter  of  fact, 
a  plane  of  easy  cleavage  lies  between  the  muscularis  of 
the  intestine  and  the  surface  of  the  tumour. 

True  tumours  of  the  broad  ligament  can  be  distinguished 
by  the  fact  that  they  are  entirely  separate  from  the  uterus, 

406 


Plate  VI. — Myoma  of  the  Right  Broad  Ligament. 


BROAD-LIGAMENT  MYOMATA  407 

which  they  displace  but  do  not  deform.  Their  relation  to 
the  uterine  artery  should  be  remembered ;  it  lies  beneath 
and  on  the  inner  side  of  the  tumour,  while  the  ureter  is 
displaced  inwards,  and  will  be  found  running  in  the  posterior 
peritoneal  layer  of  the  broad  ligament,  after  leaving  which 
it  courses  under  the  tumour  to  reach  the  bladder. 

There  are  two  methods  of  dealing  with  these  broad- 
ligament  myomata.  If  the  tumour  is  small  it  may  be 
enucleated  in  the  manner  described  for  dealing  with  broad- 
ligament  cysts  (p.  463).  If  the  tumour  is  very  large, 
vascular  or  adherent,  it  may  be  necessary  to  remove  the 
uterus  in  addition,  principally  as  a  means  of  easily  con- 
trolling the  haemorrhage.  This  method  will  be  described 
in  the  operation  for  the  second  variety  of  broad-ligament 
myoma. 

This  second  variety  may  be  termed  the  "false"  broad- 
ligament  myoma.  In  this  case  the  tumour  springs  from 
the  lateral  wall  of  the  uterine  body  or  of  the  cervix,  and 
bulges  outwards  between  the  layers  of  the  broad  ligament. 
The  uterus  is,  therefore,  part  and  parcel  of  the  tumour. 
These  tumours  distend  the  broad  ligament,  and  also  at 
times  raise  the  lateral  pelvic  peritoneum  and  invade  the 
mesocolon. 

Besides  their  relation  to  the  uterus,  they  differ  from 
the  first  variety  in  that  they  displace  the  uterine  artery 
outwards  and  upwards,  so  that  in  extreme  cases  the  uterine 
and  ovarian  vessels  are  approximated  and  run  a  parallel 
course  on  the  top  of  the  tumour.  The  ureter  is  displaced 
outwards  to  the  pelvic  wall  and,  as  a  rule,  lies  under  the 
tumour,  except  in  the  rare  lateral  cervical  myomata  already 
referred  to,  when,  together  with  the  lateral  angle  of  the 
bladder,  it  may  be  undermined  by  the  tumour  and  elevated 
on  its  upper  surface.  These  tumours,  when  small,  can 
sometimes  be  enucleated,  but  when  large  they  must  be 
dealt  with  as  follows  : 

It  is  better  to  begin  the  removal  of  the  tumours 
by  attacking  the  healthy  side  of  the  uterus.     The  reasons 


408 


GYNECOLOGICAL  SURGERY 


for  this  are,  in  the  first  place,  that  haemorrhage  can 
be  better  controlled,  and,  secondly,  that  the  uterus 
itself  constitutes  the  firmest  attachment  of  the  tumour, 
which  is  elsewhere  surrounded  by  cellular  tissue  and  peri- 
toneum. The  greatest  difficulty  in  these  cases  is  the  control 
of  the  uterine  vessels  on  the  side  of  the  tumour,  and  it  is 
often  impossible  to  secure  them  until  the  tumour  is  removed 
from  the  field  of  view.    The  concluding  stage  of  its  removal 


Fig.  275. — Hysterectomy  for  a  broad-ligament  myoma 
Dividing  the  peritoneum  over  the  front  of  the  uterus. 


has,  therefore,  often  to  be  effected  as  quickly  as  possible, 
and  this  is  materially  aided  by  the  previous  amputation 
of  the  uterus  and  clamping  of  the  uterine  vessels  on  the 
healthy  side. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation. — i.  Opening  the  abdominal  cavity. — See  p.  276. 

ii.  Clamping  and  dividing  the  ovarian  vessels  and  round 
ligament  on  the  healthy  side. — See  pp.  293-96. 

iii.  Securing  the  ovarian  vessels  and  round  ligament  on 
the  diseased   side. — The  peritoneum  over  the  front  of  the 


BROAD-LIGAMENT  MYOMATA 


409 


uterus  is  now  incised  at  the  upper  level  of.  its  loose  attach- 
ment, together  with  the  round  ligament  on  the  diseased 
side,  this  structure  having  been  previously  clamped  with 
forceps  (Fig.  275).  The  index  ringer  of  the  surgeon's  left 
hand  is  then  inserted  between  the  cut  edges  of  the  peri- 
toneum and  forced  under  the  Fallopian  tube  and  ovarian 
vessels,  which  are  thus  separated  from  the  tumour.     Two 


Fig.  276. — Clamping  the  ovarian  vessels  on  the  side 
of  the  tumour. 


pressure-forceps  having  been  applied  to  these  structures 
(Fig.  276),  they  are  divided  between  them. 

iv.  Stripping  the  anterior  peritoneal  flap. — The  peri- 
toneum is  now  stripped  from  the  upper  surface  of  the 
tumour  as  far  as  possible,  and  the  bladder  is  pushed  down 
(Fig.  277). 

v.  Clamping  the  uterine  vessels  on  the  healthy  side. 
— See  p.  298. 

vi.  Amputating  the  uterus  and  dividing  the  uterine 
vessels  on  the  diseased  side. — The  uterine  vessels  on  the 


4io 


GYNAECOLOGICAL  SURGERY 


same  side  as  the  tumour  are  secured  by  drawing  the  fundus 
of  the  uterus  over  towards  the  side  on  which  the  tumour 
lies  with  a  volsella,  cutting  through  the  uterus  at  the 
level  of  the  internal  os,  and  clamping  the  vessels  when 
they  come  into  view  or  as  they  spurt  (Fig.  278). 

vii.  Enucleating  the  tumour. — The   assistant    pulls    the 
uterus    strongly    towards    the    side    of    the    tumour,    and 


Fig.  277. — Stripping  the  peritoneum  over  the  tumour. 

the  operator,  passing  the  fingers  of  his  left  hand  between 
the  tumour  and  the  base  of  the  broad  ligament,  frees  its 
lower  surface  and  thus  enucleates  it  (Fig.  279). 

viii.  Ligaturing  the  uterine  and  ovarian  vessels. — See 
pp.  301-6. 

ix.  Obliterating  the  cavity  of  the  broad  ligament. — 
All  redundant  peritoneum  being  removed  with  the  scissors, 
it  will  usually  be  found  that  the  suture  of  the  perito- 
neal flaps  can  be  immediately  proceeded  with  (p.  306). 
Where,  however,  the  cavity  extends  deeply  into  the  broad 
ligament,  and  much  oozing  is  present,  it  may  be  obli- 
terated by  sutures  from  the  bottom  upwards.     Care  must 


BROAD-LIGAMENT  MYOMATA  4" 


Fig.  278. — -Amputating  the  uterus. 


Fig.  279. — -Completing  the  enucleation  of  the  tumour. 


412 


GYNECOLOGICAL  SURGERY 


be  taken  to  avoid  injuring  the  ureter  when  doing  this 
(Fig.  280). 

x.  Closing  the  abdominal  cavity- — See  p.   285. 

Difficulties  and  dangers. — -The  difficulties  may  be  some 
of   those  which  are  mentioned   under   the  sections  dealing 


Fig.  280. — Closing  the  peritoneal  flaps. 

with  broad-ligament  cysts  and  cervical  myomata.  The 
surgeon  must  remember  the  various  displacements  to 
which  the  ureter  is  liable,  and,  if  he  cannot  be  sure  of 
its  exact  position,  must  minimize  the  danger  of  wounding 
it  by  keeping  as  close  to  the  tumour  as  possible  whilst 
enucleating  it. 

Dressing  and  after-treatment.     See  p.  44  and  Chapter 

XXXII. 


CHAPTER    XIX 

ABDOMINAL    MYOMECTOMY 

The  operation  of  abdominal  myomectomy  has  for  its 
object  the  removal  of  one  or  more  myomatous  tumours 
from  the  uterus,  with  conservation  of  this  organ.  This 
method  is  the  ideal  one,  but  it  is  often  associated  with 
grave  disadvantages,  so  that  its  performance  has  many 
limitations.  By  myomectomy  the  necessity  of  hysterec- 
tomy is  obviated — a  point  of  great  importance  if  the 
patient  specially  objects  to  the  removal  of  the  uterus.  The 
chances  of  future  conception  are,  however,  not  great,  since 
the  majority  of  women  afflicted  with  myomata  are  past 
the  child-bearing  age.  Noble,  when  investigating  a  long 
series  of  cases,  found  that  only  10  per  cent,  of  the  women 
upon  whom  myomectomy  had  been  performed  subsequently 
conceived. 

In  regard  to  the  continuance  of  menstruation,  it  has 
to  be  remembered  that  operations  upon  uterine  myomata 
are  most  often  called  for  on  account  of  excessive  monthly 
bleeding,  which  it  is  imperative  to  cure.  The  operation 
of  myomectomy  undertaken  with  this  object  often  fails 
because  of  the  certainty  in  many  cases  of  leaving  small 
submucous  nodules  of  whose  presence  the  operator  was  in 
ignorance.  Noble,  in  the  same  series  of  cases,  found  that 
in  more  than  6  per  cent,  other  myomata  subsequently 
developed.  The  mortality  of  myomectomy,  as  estimated 
from  a  large  number  of  cases,  is  higher  than  that  of  hyster- 
ectomy, but  in  applying  such  figures  to  particular  cases 
certain  reservations  must  be  borne  in  mind. 

Small  tumours  superficially  placed,  especially  when 
pedunculated,  can  be  more  easily  and  safely  removed  than 

4*3 


4H  GYNECOLOGICAL  SURGERY 

the  whole  uterus  ;  whilst,  on  the  other  hand,  interstitial  or 
submucous  masses,  especially  when  large,  multiple,  or  situ- 
ated in  the  lower  segment,  present  great  difficulties  and  risks. 

The  risks  attendant  on  a  difficult  abdominal  myomec- 
tomy are  due  directly  or  indirectly  to  haemorrhage.  During 
the  operation  the  bleeding  may  be  so  profuse  that,  after 
all  attempts  to  check  it  have  failed,  hysterectomy  may 
have  to  be  performed  as  a  last  resource,  or  its  arrest 
may  entail  the  application  of  so  many  mass  ligatures  as 
to  leave  large  areas  of  tissue  in  danger  of  necrosis.  Even 
with  the  greatest  care,  there  is  a  likelihood  of  considerable 
oozing  taking  place  subsequently  to  the  operation,  with 
the  formation  of  a  haematoma  of  the  uterine  wall  or  a 
localized  collection  of  blood-clot  in  the  peritoneum.  In  the 
first  event  there  is  a  liability  to  septic  infection,  whilst  in 
the  second  the  presence  of  blood  in  the  peritoneum  acts 
as  an  irritant  to  the  serous  membrane  and  is  soon  followed 
by  the  appearance  of  organisms.  The  local  peritonitis 
thus  set  up  is  succeeded  by  fever  and  pain  of  some  days' 
duration,  and  probably  always  terminates  in  the  form- 
ation of  adhesions  to  omentum  and  intestine,  result- 
ing in  a  few  cases  in  intestinal  obstruction  and  in 
many  cases  in  postoperative  pain.  Of  course,  oozing 
may  occur  after  hysterectomy,  but  it  is  not  so  likely, 
and  there  can  be  no  doubt  that  the  morbidity  after  diffi- 
cult myomectomy  is  greater  than  that  after  hysterectomy. 
The  cases  in  which  myomectomy  should  be  performed 
must  therefore  be  selected.  The  operator,  when  faced  with 
the  choice  of  conserving  or  removing  the  uterus,  must 
weigh  the  relative  risks  and  advantages  as  applied  to  the 
particular  case.  We  think  that  myomectomy  is  indicated 
in  preference  to  hysterectomy  when  the  tumour,  as  far 
as  can  be  judged,  is  solitary,  when  the  symptoms  com- 
plained of  are  those  of  pressure,  of  aseptic  or  non-malignant 
degeneration,  and  when  the  risks  involved  in  its  removal 
are  not  greater  than  those  of  the  more  radical  operations. 

We   would   also   seriously   consider   the   advisability   of 


ABDOMINAL  MYOMECTOMY 


4i5 


myomectomy  in  place  of  hysterectomy,  although  associated 
with  somewhat  greater  risk,  in  the  case  of  a  young  woman 
desirous  of  having  a  child. 

In  cases,  however,  where  the  leading  symptom  is  haemor- 
rhage, and  the  patient  is  past  the  child-bearing  age,  or  the 
tumour  is  the  seat  of  septic  or  malignant  degeneration, 
hysterectomy  is  to  be  performed. 


Fig.  281. — Abdominal  myomectomy  for  a  pedunculated 
tumour  :  Incising  the  capsule  at  its  junction  with  the 
pedicle. 

I.   ABDOMINAL   MYOMECTOMY   FOR  A   PEDUNCU- 
LATED   SUBPERITONEAL    MYOMA 

By  this  operation  pedunculated  subperitoneal  fibroids 
are  removed,  the  uterus  being  conserved. 
Preparation  of  patient. — See  pp.  82-86. 
Instruments. — See  p.  276. 


4i6 


GYNAECOLOGICAL  SURGERY 


Operation,  i.  Opening  the  abdominal  cavity- — See  p.  276. 

ii.  Delivery  of  the  tumour  and  uterus. — See  p.   292. 

iii.  Section  of  the  pedicle. — The  pedicle  having  been 
clamped  with  one  or  more  pairs  of  pressure-forceps,  a 
circular  incision  is  made  through  the  peritoneum  distally 
to  the  forceps  at  the  base  of  the  pedicle  about  \  in.  from 
where  this  structure  joins  the  uterus  (Fig.  281). 


Fig.  282. — Enucleating  the  tumour. 


iv.  Enucleation  of  the  tumour. — The  peritoneum  thus 
incised  having  been  reflected  towards  the  uterus,  the  tumour 
is  enucleated  (Fig.  282). 

v.  Arrest  of  haemorrhage. — -Any  bleeding  is  controlled 
by  passing  two  or  more  silk  mattress-sutures  through  the 
peritoneum  and  deeply  to  the  cut  surface   (Fig.  283). 

vi.  Suture  of  pedicle-flaps. — The  uterine  peritoneum  is 
sutured  with  a  continuous  No.  2  silk  suture  (Fig.  284). 

Alternative  methods. — If  the  pedicle  is  thin,   it   can  be 


ABDOMINAL   MYOMECTOMY 


417 


transfixed  and  tied  in  the  same  way  as  an  ovarian  pedicle 
(see  p.  456).     If   the  tumour  cannot  be  enucleated  and  the 


Fig.  283. — Arresting  haemorrhage  from  the  pedicle  by 
mattress-sutures. 

pedicle  is  thick,  a  wedge-shaped  incision  should  be  made 
in  the  pedicle,  which  is  afterwards  closed  with  mattress- 
sutures  of  No.  4  silk. 


Fig.  284. — Closing  the  peritoneum  over  the  pedicle. 

2B 


4i8 


GYNECOLOGICAL   SURGERY 


vii.  Closing  the  abdominal  cavity. — See  p.   285. 
Dressing  and  after-treatment. — See   p.    44  and  Chapter 

XXXII. 

II.   ABDOMINAL   MYOMECTOMY   FOR   A   NON- 
PEDUNCULATED    MYOMA 

By  this  operation  myomata  imbedded  in  the  substance 
of  the  uterus  are  removed, 
the  organ  itself  being  con- 
served. 

Preparation  of  the  pa- 
tient.— See  pp.  82-86. 

Instruments. — See  p. 
276. 

Operation,  i.  Opening 
the  abdominal  cavity. — 
See  p.  276. 

ii.  Incision  of  the  cap- 
sule of  the  tumour. — The 
uterus  having  been  de- 
livered through  the  ab- 
dominal incision,  the  peri- 
toneum and  the  capsule 
covering  the  tumour  are 
incised,  the  uterus  being 
steadied  meanwhile  by  the 
assistant  (Fig.  285). 

iii.  Enucleation  of  the 
tumour. — -The  handle  of 
the  scalpel  is  then  passed 

through  the  incision,  and  by  its  aid,  with  the  assistance 
of  strong  traction  with  a  volsella,  the  tumour  is  enucleated 
from  its  capsule   (Fig.  286). 

iv.  Arrest  of  haemorrhage. — As  a  rule,  all  bleeding 
points  are  well  controlled  with  mattress-sutures  of  No.  4 
silk,  passed  deeply  to  the  bleeding  surface  (Fig.  287).  If 
any  spouting  vessel  is  seen,  it  can  be  ligatured. 


Fig.  285. — Abdominal  myomectomy 
for  a  non-pedunculated  tumour  : 
Incising  the  capsule. 


ABDOMINAL  MYOMECTOMY 


419 


Fig.  286. — Enucleating  the  tumour. 


Fig.  287. — Arresting  haemorrhage  from  the  cavity  by 
mattress-sutures. 


420 


GYNECOLOGICAL  SURGERY 


v.  Suturing  the  uterine  incision. — The  peritoneal  edges 
of  the  capsule  are  approximated  with  No.  2  silk  sutures 
(Fig.  288).  If  the  cavity  is  very  large,  it  may  be  obliterated 
with  buried  silk  sutures. 


Fig.  288. — Suturing  the  uterine  incision. 


vi.  Closing  the  abdominal  cavity- — See  p.  285. 
If   the   haemorrhage    cannot   be   controlled   by  sutures, 
hysterectomy  must  be  performed. 

Dressing  and  after-treatment. — See  p.  44   and  Chapter 

XXXII. 


CHAPTER    XX 

CESAREAN    SECTION 

Indications.— The  indications  for  Csesarean  section  may 
be  divided  into  two  classes,  absolute  and  relative. 

The  absolute  indications  are  furnished  by  conditions 
in  which  the  child  cannot  be  delivered  by  any  other  method, 
such  as  extreme  pelvic  deformity,  with  a  true  conjugate 
of  2\  in.  or  less,  cancer  of  the  cervix,  vagina  or  rectum, 
uterine  myomata,  tumours  of  the  ovary,  atresia  or  stenosis 
of  the  vagina.     These  cases  require  no  further  discussion. 

Relative  indications  are  furnished  by  cases  in  which 
there  is  a  choice  between  this  and  other  operations,  as, 
for  instance,  in  certain  cases  of  eclampsia  and  severe  ante- 
partum haemorrhage,  and  in  cases  of  moderate  pelvic 
deformity  with  a  true  conjugate  above  2 \  in. 

i.  Eclampsia. — In  those  few  and  rare  examples  of  this 
disease  where  the  fits  are  of  great  severity  and  frequency, 
and  where  the  cervix  is  rigid,  undilatable,  and  not  taken 
up,  Caesarean  section  is  indicated.  If  it  be  true  that  deli- 
very of  the  child  improves  the  chances  of  the  mother — an 
assumption  which  some  are  not  disposed  to  maintain — • 
then,  under  the  conditions  stated  above,  this  is  the  best 
operation,  the  alternative  one  of  vaginal  Caesarean  section 
being  at  term  more  difficult  and  dangerous,  while  rapid 
and  forcible  dilatation  of  the  long  and  rigid  cervix  with 
Bossi's  dilator  is  inadmissible. 

ii.  Severe  antepartum  haemorrhage. — As  a  method  of 
treatment  for  placenta  praevia,  the  weight  of  authority  is 
against  Caesarean  section,  although  a  few  obstetricians  are 
in  favour  of  it  in  very  special  cases.  As  Munro  Kerr  points 
out,  the  foetal  mortality  in  placenta  praevia  is  much  higher 

421 


422  GYNECOLOGICAL  SURGERY 

than  in  Caesarean  section — 60  per  cent,  as  against  5  per 
cent,  at  the  most.  On  the  other  hand,  the  maternal  mor- 
tality of  placenta  praevia  varies  from  4  per  cent,  to  8  per 
cent.,  whereas  that  of  Caesarean  section  (except  under  very 
favourable  conditions)  is  higher.  In  any  case,  when  the 
bleeding  commences  before  labour  has  started,  and  when, 
because  of  the  relative  sizes  of  the  child  and  the  genital 
canal,  labour  will  be  difficult,  the  mother  would  have  a 
better  chance  with  Caesarean  section,  as  also  she  would 
in  cases  of  central  placenta  praevia,  where  the  bleeding  is 
serious,  and  especially  when,  in  addition,  the  cervix  is  rigid. 
In  severe  cases  of  concealed  accidental  haemorrhage  the 
proper  treatment  is  Caesarean  section,  either  by  the  vaginal 
or  the  abdominal  route,  depending  upon  the  practice  of 
the  operator.  The  abdominal  operation  is  certainly  much 
easier  to  perform  than  the  vaginal,  and  there  is  less  risk 
of  damaging  the  bladder,  while  subsequent  removal  of 
the  uterus,  if  it  be  indicated,  is  performed  with  more  advan- 
tage. On  the  other  hand,  by  the  abdominal  route  there  is 
more  chance  of  infection  and  greater  shock. 

iii.  Moderate  pelvic  contraction. — With  a  true  con- 
jugate below  3  in.,  Caesarean  section  is  most  certainly 
the  operation  of  election  if  the  child  be  alive,  the  patient 
in  good  condition,  and  the  circumstances  favourable.  The 
exceptions  to  this  rule  are  when  the  child  is  dead  or  dying 
(heart-beats  sixty  per  minute  or  less),  when  the  patient 
is  septic,  when  repeated  attempts  at  delivery  have  been 
made  with  the  forceps  or  by  other  methods,  when  many 
vaginal  examinations  have  been  made,  when  the  patient 
has  been  long  in  labour  and  the  membranes  have  been 
ruptured  for  some  time,  when  the  surroundings  are  unsuit- 
able, or  when  the  services  of  a  competent  surgeon  cannot  be 
obtained.  Under  these  conditions  the  risk  to  the  mother 
will  be  less  if  the  child  be  delivered  by  craniotomy,  for  it 
is  in  such  adverse  circumstances  that  the  maternal  mor- 
tality of  Caesarean  section  rises  to  8  per  cent.,  or  higher. 
The   maternal   mortality   of   craniotomy   is   not,    however, 


CESAREAN  SECTION  423 

low,  Paul  and  Bar  having  reported  two  series  of  cases  with 
a  death-rate  of  11 -5  per  cent,  and  0/3  per  cent,  respectively  ; 
and  although  these  figures  are  high,  they  more  or  less 
agree  with  the  experience  of  others. 

With  a  true  conjugate  of  3  to  3J  in.  Caesarean  section 
is,  we  think,  undoubtedly  the  proper  treatment,  supposing 
it  can  be  carried  through  with  strict  aseptic  precautions, 
in  suitable  surroundings,  by  an  operator  used  to  abdo- 
minal surgery,  and  before  the  patient  has  in  any  way  been 
interfered  with  either  prior  to  or  at  the  commencement 
of  labour,  the  child  being  alive  and  well.  In  the  absence  of 
such  qualifications  an  attempt  may  be  made  to  deliver  with 
forceps  ;  but  not  much  force  must  be  used,  and  if  the  head 
is  movable  above  the  brim  this  method  is  contra-indicated. 
If  unsuccessful,  craniotomy  should  be  performed.  If  the 
child  is  dead,  its  head  should,  of  course,  be  perforated. 
There  is  another  alternative — namely,  pubiotomy — if  the 
child  is  alive  and  the  disparity  between  the  head  and  the 
pelvis  is  not  so  great  that  natural  delivery  may  not  be 
reasonably  expected  to  take  place  after  the  pubis  has 
been  divided.  The  induction  of  premature  labour  with  a 
conjugate  as  small  as  this  so  seldom  results  in  the  birth 
of  a  living  child,  or  of  one  that  will  survive  many  weeks, 
that  it  has  been  almost  abandoned  for  such  cases.  It  is 
true  that  the  maternal  mortality  with  induction  is  prac- 
tically nil  (and  the  patient  should,  of  course,  be  informed 
of  this),  yet  under  the  conditions  of  favourable  time,  place, 
and  circumstances  that  may  be  commanded,  and  where 
the  patient  has  early  sought  advice,  Caesarean  section  is 
a  very  safe  operation,  the  mortality  being  probably  under 
1  per  cent,  for  such  cases  in  skilled  hands. 

Where  the  true  conjugate  is  from  3!  to  3!  in.,  very 
careful  consideration  of  all  the  factors  will  be  necessary. 
If  the  woman  has  previously  been  through  labour,  the 
history  will  afford  most  useful  information,  as,  indeed, 
it  will  in  degrees  of  contraction  greater  than  those  we 
are    now   dealing   with.       There    may   have    been    one    or 


424  GYNECOLOGICAL  SURGERY 

more  previous  and  unsuccessful  attempts  to  procure  a 
living  child  by  the  induction  of  premature  labour.  Again, 
the  parents  may  insist  upon  every  precaution  being  taken 
to  obtain  a  living  child.  In  such  cases  it  will  be  best  to 
examine  the  patient  during  the  last  weeks  of  pregnancy, 
and,  if  the  child's  head  can  be  pressed  through  the  brim 
of  the  pelvis,  to  let  labour  start,  having  previously  made 
all  preparations  for  Csesarean  section  ;  then,  if  the  head 
becomes  engaged  and  is  advancing,  labour  may  be  allowed 
to  terminate  naturally  or  with  the  aid  of  forceps.  If  the 
head  .does  not  engage,  Caesarean  section  should  be  per- 
formed, after  perhaps  one  or  two  gentle  attempts  with  the 
forceps.  The  patient  may  not  be  seen  till  labour  has 
commenced,  and,  although  the  conjugate  is  over  3^  in., 
the  head  may  not  engage.  In  these  circumstances  the 
obstruction  is  probably  due  to  the  size  of  the  child.  Caesarean 
section  is  indicated  and  we  have  performed  it  under  such 
conditions,  the  child  weighing  I2|  lb. 

At  3!  in.  the  alternative  of  inducing  premature  labour 
is  rightly  to  be  considered.  The  induction  of  premature 
labour,  if  the  patient  is  not  less  than  thirty-six  weeks 
pregnant,  will  in  most  cases  give  a  satisfactory  result,  and, 
therefore,  should  be  tried  if  the  patient  is  seen  at  this  time, 
at  any  rate  for  a  first  pregnancy.  If,  however,  it  has 
previously  been  tried  and  failed,  this  would  have  an 
important  bearing  on  the  choice  of  treatment.  It  must 
also  be  remembered  that  boys'  heads  are  generally  larger 
than  girls',  and  that  the  first  baby  is  apt  to  be  smaller 
than  those  born  subsequently. 

Pubiotomy  is  successfully  performed  in  cases  of  this 
class  as  an  alternative  to  Caesarean  section,  particularly 
in  those  cases  where,  the  head  having  engaged,  moderate 
forceps-traction  has  not  succeeded  in  bringing  it  down, 
yet  the  disparity  is  not  so  great  but  that  the  extra  half- 
inch  added  to  the  conjugate  by  the  operation  will  allow 
the  head  to  pass. 

Forceps-traction,    or   version   alone,  will   often   success- 


CESAREAN  SECTION  425 

fully  deliver  women  with  contraction  of  this  degree.  If 
they  fail  (with  the  reservation  mentioned  in  the  last  para- 
graph) the  head  should  be  perforated,  while  for  dead 
children  this  is  the  only  method  of  delivery  indicated. 

Preparation  of  the  patient. — See  pp.  82-86. 

Position  of  the  patient. — Lying  flat  on  her  back. 

Instruments. — See  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity. — See  p.  276. 
The  upper  limit  of  the  incision  should  not  reach  above 
the  umbilicus.  It  is  well  to  remember  that,  in  cases  where 
Csesarean  section  is  necessary,  the  bladder  will  very  often 
be  dragged  high  up  into  the  abdomen,  so  that  there  is  great 
danger  of  wounding  it  if  the  incision  is  carried  too  low. 

Some  surgeons,  before  opening  the  uterus,  have  de- 
livered it  through  the  abdominal  wound.  This  method 
should  not  be  followed  except  when  the  uterine  contents 
are  septic,  in  which  case  there  would  be  less  danger  of 
infecting  the  peritoneal  cavity. 

ii.  Opening  the  uterus. — The  uterus,  which  may  have 
rotated,  is  so  manipulated  that  the  centre  of  its  anterior 
surface  corresponds  with  the  centre  of  the  abdominal 
wound.  The  abdominal  parietes  are  then  pressed  against 
the  uterus  by  the  assistant,  so  as  to  prevent,  as  far  as 
possible,  any  liquor  amnii  escaping  into  the  peritoneal 
cavity.  An  incision  of  about  2  in.  is  now  rapidly 
made  through  the  anterior  surface  of  the  uterus  in  the 
middle  line  (Fig.  289).  This  incision  is  commonly  made 
through  the  upper  segment  of  the  uterus  because  of  the 
more  vigorous  retractility  of  this  portion  of  the  wall. 
In  most  cases  the  parietal  incision  described  will  allow  of 
this  being  easily  done,  but  in  some  cases,  and  especially 
in  those  where  there  is  an  excessive  amount  of  liquor 
amnii,  or  where  the  head  is  high  out  of  the  pelvis, 
most  of  the  upper  segment  will  be  above  the  superior 
limit  of  the  parietal  incision.  In  this  event,  access  to  the 
desired  site  for  the  uterine  incision  may  be  effected  by 
lifting   the    upper    edges    of   the    parietal   wound   upwards 


426 


GYNECOLOGICAL  SURGERY 


and  outwards,  as  shown  in  Fig.  289.  This  is  better  than 
extending  the  incision  above  the  umbilicus,  since  it  pre- 
vents extrusions  of  the  bowel  when  the  uterus  is  delivered 
through    the    abdominal    wound.      There    is,    however,    no 


Fig.  289. — Caesarean  section  :    Incising  the  uterus. 

grave  objection,  while  there  are  certain  advantages,  such 
as  accessibility  and  easy  delivery  of  the  child,  in  making 
the  incision  through  the  lower  segment.  The  uterine  wall 
being  divided,  the  membranes,  if  not  already  incised, 
are  ruptured,  and  the  surgeon  slips  the  first  and  second 
fingers  of  his  left  hand  into  the  uterine  cavity  and  enlarges 
the  uterine  incision  to  about  4  in.  (Fig.  290). 


CESAREAN  SECTION 


427 


The  operator  must  be  careful  not  to  injure  the  child 
with  the  scalpel  as  he  is  incising  the  uterus. 

At  times  the  bleeding  is  very  free  when  the  muscle- 
wall  is  being  cut  through,  more  especially  if  the  placenta 
happens  to  be  situated  on  the  anterior  wall,  and  for  this 
reason  some  operators  advise  that,  if  possible,  the  situation 
of  the  placenta  should  first   be  determined,  and,  if  neces- 


Fig.  290. — Enlarging  the  uterine  incision. 


sary,  an  effort  made  to  avoid  it  by  incising  the  uterus 
in  some  other  place.  There  is  no  necessity,  however,  for 
this,  and  no  notice  should  be  taken  of  the  bleeding.  If 
the  placenta  is  in  the  way  it  should  first  be  rapidly  re- 
moved with  the  hand.  After  the  delivery  of  the  child  the 
bleeding  is,  as  a  rule,  arrested  by  uterine  retraction. 

iii.  Delivery   of  the   child.— Having   been   delivered   by 
traction  on  a  leg  (Fig.   291),  the    child    is    encouraged  to 


428 


GYNECOLOGICAL  SURGERY 


breathe,  and  when  the  umbilical  cord  has  stopped  pulsating 
it  is  clamped  in  two  places  with  pressure-forceps,  and, 
the  cord  being  cut  between  them,  the  child  is  freed.  In  cases 
where  profuse  haemorrhage  ensues,  as,  for  instance,  when 
the  placenta  is   on  the   anterior   wall,   it   is   impossible   to 


Fig.  291. — Delivering  the  child. 

wait  so  long,  and  the  cord  must  be  at  once  clamped  and 
divided. 

iv.  Removal  of  the  placenta. — -The  placenta  and  mem- 
branes are  removed  with  the  hand,  and,  if  adherent,  care 
must  be  taken  in  peeling  them  off  not  to  leave  any  pieces 
behind  (Fig.  292). 

v.  Delivery  of  the  uterus.  —  After  the  placenta  is 
removed,  the  retracted  uterus  is  delivered  through  the 
abdominal   incision.      If   the   extent   of   the   cut   has   been 


CESAREAN   SECTION 


429 


rightly  judged,  no  swab  to  pack  off  the  intestines  is  required. 
If  the  incision  is  too  large,  a  swab  must  be  inserted  for 
this  purpose. 

vi.  Suturing  the  uterus. — The  wound  in  the  uterus  is 
closed  by  a  series  of  interrupted  sutures  of  No.  4  silk  passed 
deeply  through  the  peritoneum  and  muscle  on  either  side, 


Fig.  292. — Removing  the  placenta. 

but  not  through  the  mucous  membrane  (Fig.  293),  and 
tied.  A  second  series  should  then  be  introduced  between 
them  ;  these  should  be  of  the  Lembert  variety,  and  should, 
when  tied,  bury  those  of  the  first  row.  Where  the  uterine 
wall  is  very  rigid,  Lembert  sutures  may  cut  out,  in  which 
case  ordinary  interrupted  ones  should  be  used  for  the 
second  series  as  for  the  first  (Fig.  294).  In  all  about  twelve 
to  fourteen  sutures  will  be  required,  as  a  rule. 


430 


GYNAECOLOGICAL   SURGERY 


vii.  Peritoneal  toilet.  — ■  Any  blood  or  liquor  amnii 
which  may  have  escaped  into  Douglas's  pouch  should  be 
removed  with  a  swab,  after  which  the  uterus  is  returned 
into  the  abdomen. 

viii.  Closing  the  abdominal  cavity- — See  p.   285. 

Difficulties    and    dangers,     i.  Delivering    the    child. — If 


Fig.  293. — Inserting  the  deep  sutures. 


the  head  of  the  child  has  partly  entered  the  brim  of  the 
pelvis,  some  difficulty  may  be  experienced  in  extracting 
it.  Under  these  conditions  the  uterine  incision  may  have 
to  be  enlarged  and  the  head  disengaged,  perhaps  by 
jaw-traction,  whilst  an  assistant  forces  it  up  by  vaginal 
manipulation. 

If  the  head  is  impacted  in  the  pelvis,  Csesarean  section, 
unless   absolutely  necessary  from  inability  to  deliver  the 


CESAREAN  SECTION 


43i 


child  by  any  other  method,  should  never  be  done,  as  in 
the  first  place  the  child  will  certainly  be  dead  by  the  time 
it  is  delivered,  and  secondly,  the  uterus  may  be  so  injured 
in  the  process  of  delivery  that  hysterectomy  must  be 
performed.  Before  now  it  has  been  found  necessary  to 
perforate  the  head  before  the  child  could  be  extracted 
from  the  brim. 


Fig.  294. — Inserting  the  superficial  sutures. 


ii.  Hsemorrhage. — In  most  cases  all  bleeding  from  the 
cut  uterine  wall  ceases  as  the  organ  retracts,  but  a  few 
spurting  arteries  may  remain.  Hsemorrhage  from  the 
wound-edges  can  always  be  controlled  by  the  sutures  that 
close  the  incision  in  the  uterus,  and  if  this  is  the  only  bleed- 
ing that  is  going  on  it  should  be  immediately  proceeded 
with.  In  some  cases,  however,  owing  to  deficient  retrac- 
tion, free  bleeding  occurs  from  the  placental  site.  This 
must  be  arrested  before  the  uterus  is  closed,  by  massaging 
the  organ,  by  inserting  in  it  a  swab  wrung  out  of  boiling 


432  GYNECOLOGICAL  SURGERY 

water,  and  by  administering  20  minims  of  ergotin  by 
intramuscular  injection.  The  loss  may  be  minimized  if 
the  assistant  grasps  the  lower  uterine  segment  and  com- 
presses the  uterine  arteries  until  the  stimulating  measures 
described  have  time  to  act. 

In  those  rare  cases  in  which  the  bleeding  cannot  be 
controlled  by  these  means  the  uterus  must  be  amputated 
by  the  method  described  at  p.  292. 

After-treatment. — See  p.  44  and  Chapter  xxxn.  The 
mother  should  suckle  her  child  unless  there  is  some  contra- 
indication present. 

Should  the  patient  be  sterilized? — This  depends  upon 
the  condition  for  which  the  operation  is  performed. 
If  the  operation  is  necessary  because  of  obstruction 
from  a  tumour  of  the  uterus,  this  organ  should, 
of  course,  be  removed  by  hysterectomy  after  the  child 
has  been  delivered,  unless  the  tumour  can  be  enucleated. 
If  the  operation  is  done  for  osteomalacia,  improvement 
or  cure  of  the  disease  is  said  to  occur  if  the  ovaries  are 
removed,  and  in  this  case,  as  the  uterus  will  be  of  no 
further  use,  it  should  be  removed  also.  When,  however, 
the  operation  is  performed  for  obstruction  due  to  other 
varieties  of  contracted  pelvis,  or  in  some  rare  cases  of 
accidental  and  unavoidable  haemorrhage,  opinions  differ 
very  markedly.  If  Caesarean  section  is  necessary  for 
concealed  accidental  haemorrhage,  it  is  usually  advisable 
to  remove  the  uterus  unless  a  very  firm  retraction  is 
secured,  rendering  the  occurrence  of  post-partum  haemor- 
rhage unlikely.  In  cases  of  placenta  praevia,  where  it  is 
necessary  to  perform  ,Caesarean  section,  the  uterus  can 
usually  be  conserved.  When  the  operation  is  performed 
for  contracted  pelvis,  the  question  of  sterilization  requires 
most  careful  consideration. 

From  the  national  standpoint,  sterilization  may  be  the 
means  of  depriving  the  community  of  useful  citizens ;  from 
the  domestic,  the  life  of  the  Caesarean  child  obtains  thereby 
an  additional  importance,  as  no  other  children  are  possible 


C/ESAREAN   SECTION  433 

to  the  woman ;  from  the  point  of  view  of  the  interests 
of  the  patient  herself,  the  sterility  thus  acquired  may,  in 
the  case  of  a  widow  or  an  unmarried  girl,  be  a  serious 
handicap  to  the  chance  of  future  marriage,  the  risk  of 
Cesarean  section  is  not  increased  by  the  repetition  of  its 
performance,  whilst  on  the  other  hand  sterilization  has 
the  advantage  of  removing  the  menace  from  a  deformity 
which  in  itself  is  a  misfortune. 

We  are  of  opinion  that  the  pros  and  cons  for  steriliza- 
tion should  be  fully  explained  to  the  patient  and  her  hus- 
band, and  the  decision  left  to  them.  If  they  do  not  express 
a  distinct  wish  in  the  matter  and  the  choice  is  left  to  the 
operator,  he  should  decide  against  sterilization,  since,  if 
the  domestic  aspect  of  its  performance  be  indifferent  to 
the  husband  and  wife,  it  behoves  him  to  have  regard  to 
the  interests  of  the  community  at  large. 

If,  on  the  other  hand,  the  patient  and  her  husband 
wish  to  avoid  the  possible  repetition  of  the  operation,  the 
woman  should  be  sterilized,  but  the  operator  should  obtain 
leave  to  omit  this  step  if  the  child  is  born  dead  or  appears 
unlikely  to  survive.  In  respect  to  this  last  point,  it  is 
of  great  importance  that  the  child  should  be  very  care- 
fully examined  directly  it  is  born.  The  rectum  in  par- 
ticular should  be  investigated,  since  impermeability  of 
this  organ  has  been  overlooked.  The  only  efficient  method 
of  sterilization,  apart  from  removal  of  the  uterus,  is  to 
remove  both  Fallopian  tubes,  such  procedures  as  simple 
ligature  or  division  between  ligatures  having  failed  on 
many  occasions. 


ZQ 


CHAPTER    XXI 
UTRICULOPLASTY 

Apart  from  its  reproductive  significance  it  is  doubtful 
whether  the  monthly  flow  serves  any  useful  purpose,  for 
it  is  quite  certain  that  the  total  absence  of  menstruation 
is  compatible  with  perfect  health,  and  even  in  normal 
women  its  presence  is  always  attended  with  discomfort 
and  often  with  some  degree  of  pain. 

In  exceptional  cases,  where  a  young  woman  is  suffering 
from  intractable  and  serious  haemorrhage  not  associated 
with  a  myoma  or  other  tumour  of  the  uterus,  and  at  the 
same  time  has  a  strong  objection  on  the  score  of  senti- 
ment to  the  arrest  of  menstruation,  or  is  very  anxious  to 
bear  children,  the  operation  to  which  we  have  applied  the 
term  utriculoplasty  is  an  alternative  to  subtotal  hysterec- 
tomy. The  operation,  first  described  by  Kelly,  aims  at 
the  formation  of  a  utriculus,  which,  whilst  preserving  suf- 
ficient of  the  corporeal  endometrium  to  allow  of  menstrua- 
tion, is  not  large  enough  to  permit  excessive  loss.  *  We 
have  performed  this  operation  successfully.  There  are 
no  statistics  at  present  which  would  enable  one  to  form 
any  definite  conclusions  as  to  its  value.  The  cases  we  have 
treated  thus  have  all  done  well,  and  the  object  of  the 
operation,  viz.  to  arrest  the  excessive  haemorrhage,  was 
attained  in  them  all.  Our  first  patient  became  pregnant 
six  months  after  the  operation.  The  pregnancy  proceeded 
normally  until  the  seventh  month,  when  labour  came  on 
naturally.  The  child  was  born  alive  and  survived,  the 
patient  making  a  good  recovery. 

This  case  shows  that  the  diminished  uterus  is  still 
capable   of  physiological  hypertrophy,  and   that   the   risks 

434 


UTRIGULOPLASTY 


435 


attending  future  pregnancy,  which  might  appear  formidable, 
are  not  so  serious  as  to  make  it  proper  to  sterilize  the  patient 
by  resecting  the  tubes  when  performing  the  utriculoplasty. 
Such  sterilization,  indeed,  would  deprive  the  operation 
of  half  its   value,    and   would   give   it   but    a   sentimental 


Fig.  295. — Utriculoplasty  :    Removing  a  wedge-shaped 
portion  of  the  uterus. 


value  over  subtotal  hysterectomy,  with  which  operation 
the  risks  are  probably  about  equal  when  it  is  performed 
for  the  same  class  of  case. 

Just  as  the  pregnant  uterus  may  rupture  at  the  cicatrix 
of  an  old  Cesarean  wound,  so  rupture  after  utriculoplasty 
is  a  possibility ;  but  in  the  case  recorded,  at  any  rate,  no 
such  disaster  followed. 

It  would  be  wise,  however,  to  let  a  year  elapse  before 


436 


GYNECOLOGICAL  SURGERY 


permitting  the  chance  of  pregnancy,  and  if  pregnancy 
occurs  the  patient  should  be  kept  under  observation. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity. — See 
p.  276. 


Fig.  296. — Inserting  the  mattress-sutures. 


ii.  Removal  of  portion  of  the  uterus.- — A  wedge-shaped 
piece  of  the  uterus  is  removed  as  indicated  in  Fig.  295, 
having  its  base  at  the  fundus  and  its  apex  at  the  internal 
os.  The  portion  resected  includes  the  mucous  membrane, 
but  leaves  a  portion  on  either  side  of  the  V-shaped  area  of 
excision.  The  area  of  contemplated  excision  should  first 
be  marked  out  with  the  point  of  the  scalpel,  and  should 
extend  above  so  as  to  include  the  entire  fundus  as  far  out 


UTRIGULOPLASTY  437 

on  either  side  as  a  third  of  an  inch  from  the  tubo-uterine 
junction. 

iii.  Formation  of  the  utriculus. — The  raw  edges  of  the 
cut  uterine  wall  are  now  approximated  by  mattress-sutures 
of  silk  (Fig.  296)  to  control  bleeding,  and  the  formation 
of  the  utriculus  is  completed  by  a  continuous  silk  suture 
along  the  whole  line  of  junction  of  the  two  halves  (Fig.  297). 


Fig.  297. — Completing  the  utriculus. 

Dangers.  —  The  bleeding  in  all  our  cases  has  been  at 
/once  checked  by  the  sutures.  Exceptionally  it  might  be 
difficult  to  control,  in  which  case  a  hysterectomy  would 
be  necessary.  As  there  is  a  large  surface  of  suturing  on 
the  uterus,  strict  asepsis  is  very  important. 

Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 


CHAPTER    XXII 

OPERATIONS    TO    REMEDY   MALPOSITIONS    OF 
THE   UTERUS 

I.    VENTRO-SUSPENSION    OF    THE    UTERUS 

Ventro-suspension  is  indicated  in  cases  of  retroversion 
with  symptoms  in  which  a  pessary  is  of  no  use,  cannot  or 
will  not  be  tolerated,  or  is  unsuitable  by  reason  of  co-existent 
disease  of  the  appendages.  It  is  an  excellent  operation  for 
prolapse,  but  only  if  combined  with  a  perineoplasty.  We 
have  also  frequently  employed  it  after  the  removal  of 
diseased  Fallopian  tubes  or  appendages,  to  prevent  the 
postoperative  retroversion  and  adhesion  of  the  uterus 
which  so  commonly  follow  such  an  operation.  With  regard 
to  its  application  to  cases  of  retroversion  uncomplicated 
by  appendage  disease,  we  have  for  some  time  in  this  con- 
dition shortened  the  round  ligaments  intraperitoneally  in 
preference  to  performing  ventro-suspension,  as  being  an 
operation  more  anatomically  correct. 

Preparation  of  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation.  i.  Opening  the  abdominal  cavity-  —  See 
p.  276.  In  this  operation  the  peritoneum  should  not  be 
divided  so  low  down  as  the  fascia. 

ii.  Raising  the  uterus. — The  uterus  which  is  prolapsed 
or  retroverted,  as  the  case  may  be,  is  brought  up  into  the 
wound  by  the  surgeon  passing  the  first  and  second  fingers 
of  his  left  hand  behind  it,  and  then  drawing  it  forward. 
If  it  is  fixed  by  any  adhesions,  these  will,  of  course,  have 
first  to  be  separated. 

iii.  Passing  the  sutures. — The  lower  edge  of  the  parietal 
peritoneum  having  been  pulled  well  up  over  the  uterus,  a 

438 


VENTRO-SUSPENSION  OF  UTERUS 


439 


No.  4  silk  suture  is  first  passed  through  the  parietal  peri- 
toneum and  uterine  wall  on  its  anterior  aspect  below  the 
lower  angle  of  the  incision  in  the  former  (Fig.  298). 
This  suture  is  tied  by  the  assistant  (Fig.  299),  and  the  ends, 
being  left  long,  are  used  to  keep  the  uterus  forward  during 


Fig.  298. — Ventro-suspension  : 
Inserting  the  retaining  suture. 

the  passage  of  the  subsequent  sutures.  After  this,  two  or 
three  sutures  are  passed  through  the  fascia  and  peritoneum 
of  the  left  side,  then  through  the  peritoneum  and  muscle  of 
the  uterus,  and  lastly  through  the  peritoneum  and  fascia 
of  the  right  side  (Fig.  300).  These  sutures  are  then  tied 
(Fig.  301). 

iv.  Closing  the  abdominal  cavity. — The  rest  of  the  cut 
edges  of  the  peritoneum,  the  fascia,  and  skin  are  closed  in 
the  usual  manner  (p.  285). 


440  GYNECOLOGICAL  SURGERY 


Fig.   299. — Tying  the  retainin 
suture. 


Fig.  300.— Passing  the  rest  of 
the  sutures. 


VENTRO-SUSPENSION   OF   UTERUS        441 

Dressing  and  after-treatment. — See   p.  44  and   Chapter 

XXXII. 

Dangers. — In  ventro-suspension  the  object  in  view  is 
to  procure  an  adhesion  between  the  anterior  surface  of  the 
uterus  and  the  parietal  peritoneum,  which  will  hold  up 
the  uterus  if  prolapsed  or  keep  it  in  a  position  of  ante- 
version  if  it  is  backwardly  displaced. 

If  only  the  parietal  peritoneum  is  sutured  to  the  uterus, 
there    is    no    danger    of    any    complication    arising    during 


Fig.  301. — Tying  the  sutures. 

pregnancy  or  child-birth  which  could  be  rightly  attributed 
to  the  operation ;  but  if  the  parietal  fascia  is  included  in 
addition,  there  is  some  risk  of  such  a  complication  in  pro- 
portion to  the  area  of  resulting  adhesion. 

On  the  other  hand,  if  the  fascia  is  not  included  in  the 
fixation  stitches,  the  weight  of  the  uterus  drags  the  parietal 
peritoneum  off  the  anterior  abdominal  wall  and  rapidly 
forms  a  long  ligament,  until  at  length  in  many  cases  the 
displacement  returns,  with  the  additional  disadvantage  of 


442  GYNAECOLOGICAL  SURGERY 

a  narrow  band  stretching  across  the  peritoneal  cavity, 
around  which  intestine  may  get  twisted.  The  method 
that  we  have  described  aims  at  steering  between  the  dis- 
advantages of  loose  peritoneal  suspension  and  absolute 
fascial  fixation.  We  have  found,  as  a  result  of  examination 
when  the  abdominal  cavity  has  been  reopened  for  some 
subsequent  disease,  that  at  the  end  of  a  year  or  more  the 
technique  we  follow  has  resulted  in  the  formation  of  a 
short  strong  ligament  about  half  an  inch  in  length,  which 
is  sufficient  to  hold  up  the  uterus  not  only  in  cases  in 
which  the  operation  is  undertaken  for  retroversion,  but 
in  those  in  which  there  is  also  prolapse. 

If  the  patient  subsequently  becomes  pregnant,  there  is 
a  danger  of  some  complication  arising  during  pregnancy  or 
child-birth,  especially  when  many  fascia  sutures  have  been 
inserted.  We  have  knowledge  of  a  case  in  which  Csesarean 
section  had  to  be  performed  after  the  uterus  had  been 
fixed  by  ventro-suspension,  the  pelvis  being  of  normal 
size  and  the  child  in  a  normal  position,  and  also  of  a  case 
in  which  miscarriage  occurred  twice,  and  each  time  the 
haemorrhage  was  so  severe  that  the  patient  nearly  died. 
In  our  own  practice  we  are  unaware  of  any  bad  results 
in  these  respects.     (See  also  Chapter  xli.) 

It  has  happened  that  intestine,  slipping  undetected 
between  the  uterus  and  parietes,  has  been  wounded  when 
the  sutures  were  passed,  or  has  become  adherent  there, 
with  resulting  obstruction  later  on,  as  in  two  cases  we 
have  knowledge  of. 

As  the  method  described  has  in  our  experience  fulfilled 
the  objects  in  view,  whether  the  operation  was  performed 
for  retroversion  or  prolapse,  whether  the  patient  was  of 
fertile  age  or  not,  nor  has  it  been  followed,  as  far  as  we 
are  aware,  by  any  evil  results,  we  have  not  practised  any 
of  the  alternative  methods  of  ventro-suspension  advocated 
by  certain  authorities,  such  as  fundal  fixation  or  posterior 
fixation,  both  of  which  we  consider  to  be  greatly  inferior, 
especially  in  women  of  the   child-bearing  age. 


SHORTENING   OF  ROUND   LIGAMENTS     443 


With  regard  to  ventro -fixation,  in  which  the  anterior 
surface  of  the  uterus  is  first  denuded  of  peritoneum  and 
then  sutured  to  the  fascia  without  the  intervention  of  the 
parietal  peritoneum,  we  deem  it  absolutely  unjustifiable 
before  the  menopause,  and  at  no  time  more  efficacious  than 
the  method  we  practise.  This  operation,  from  a  careful 
study  of  the  reported  cases,  appears  in  its  sequelae  to  be 
highly  dangerous  in  the  event  of  pregnancy. 

II.    INTRAPERITONEAL    SHORTENING    OF   THE 
ROUND    LIGAMENTS 

Indications. — This  operation  is  indicated  as  an  alter- 
native to  ventro-suspension,  especially  in  women  of  a 
child-bearing  age,   in  cases   of  retroversion  giving  rise   to 


Fig.  302. — Intraperitoneal  shortening 
of  the  round  ligaments  :  Making 
the  transverse  skin-incision. 


symptoms  in  which  a  pessary  cannot  or  will  not  be  borne 
or  does  not  give  relief.  It  is  an  ineffective  operation 
for  prolapse,  because  it  does  not  effect  a  sufficiently  direct 


444 


GYNECOLOGICAL  SURGERY 


pull  upwards  upon  the  pelvic  floor,  and  its  performance 
actually  tends  to  make  a  cystocele  much  worse  by  relaxing 
the  anterior  wall  of  the  genital  canal.  It  should  not,  there- 
fore, be  performed  for  retroversion  associated  with  either 

of  these  conditions. 

Preparation  of  the 
patient. — See  p.  82. 

Instruments.  —  See 
p.  276.  A  special  pair 
of  forceps  (Fig.  $a), 
curved  needles,  and  silk 
sutures  Nos.  2  and  4 
will  also  be  required. 
Operation,  i.  Open- 
ing of  the  abdominal 
cavity. — See  p.  276. 
In  this  operation  a 
transverse  skin-inci- 
sion may  be  made 
across  the  upper  part 
of  the  mons  veneris 
with  cosmetic  advan- 
tage, for  when  the 
pubic  hairs  grow  again 
no  scar  will  be  visible. 
If  this  incision  is 
chosen,  the  skin  will 
have  to  be  dissected 
freely  from  the  fascia 
at  its  upper  edge  (Fig. 
302).  The  fascia  and  peritoneum  are  then  divided  in  the 
usual  direction,  the  operator  retracting  the  upper  edge  of 
the  skin-incision  to  give  more  room  (Fig.  303). 

ii.  Pulling  up  the  uterus. — A  retractor  having  been 
inserted  into  the  upper  angle  of  the  wound,  the  uterus  is 
pulled  up. 

iii.  Ligature     of    the    round    ligaments.  —  The     round 


Fig.  303. — Incising  the  fascia 
vertically. 


SHORTENING  OF  ROUND   LIGAMENTS    445 

ligament  on  either  side  is  seized  just  externally  to  its  attach- 
ment to  the  uterus  with  a  pair  of  pressure-forceps,  and  a 
double  ligature  8  in.  long  of  No.  4  silk  is  passed  round  it, 
and  tied  about  half  an  inch  farther  out  (Fig.  304). 

iv.  Passing  the  round-ligament  forceps. — The  fascia  of 
the    rectus    is    incised   about   half   an   inch   from   the   cut 


Fig.  304. — Placing  the  guide  ligature 
on  the  round  ligament. 


edge  forming  the  margin  of  the  abdominal  wound,  and 
the  round-ligament  forceps  is  then  gently  forced  between 
the  rectus  muscle  and  fascia  (Fig.  305),  and  subsequently 
between  the  aponeurosis  of  the  internal  oblique  and  the 
peritoneum,  until  the  situation  of  the  internal  abdo- 
minal ring  is  reached,  i.e.  the  point  where  the  round 
ligament  is  seen  to  emerge  into  the  abdominal  cavity. 
The  point  of  the  forceps  is  now  directed  inwards  and  is 


446 


GYNECOLOGICAL  SURGERY 


made  to  follow  a  track  parallel  to  the  round  ligament, 
immediately  in  front  of  it,  and  under  the  peritoneum  of 
the  broad  ligament,  until  the  site  of  the  ligature  is  reached 
(Fig.  306).  This  part  of  the  operation  is  much  facilitated 
by  the  assistant  making  traction  on  the  ligature  so  that 
the  round  ligament  becomes  taut  and  apparent.  The 
forceps  is  now  passed  through  the  peritoneum  at  this  spot 

into  the  abdo- 
minal cavity 
(Fig.  307),  the 
ends  of  the  liga- 
ture which  has 
been  applied  to 
the  round  liga- 
ment are  seized, 
and  the  ligature 
is  pulled  back 
through  the 
path  made  by 
the  forceps  (Fig. 
308)  until  a 
piece  of  doubled 
round  ligament 
presents  at  the 
cut  in  the  fas- 
cia of  the  rectus 
about  half  an 
inch  from  the 
primary  incision 
(Fig.  309).  If  the  points  cannot  be  forced  through  the 
peritoneum,  the  latter  must  be  nicked  with  the  scalpel. 
The  same  proceeding  is  then  carried  out  on  the  opposite  side, 
v.  Anchoring  the  round  ligaments  to  the  fascia  of 
the  rectus. — Needles  are  threaded  on  the  ends  of  each 
ligature,  and  each  round  ligament  is  sutured  to  the  edges 
of  the  small  incision  in  the  fascia,  while  with  the  same 
knot  the  incision  itself  is  closed  (Fig.  310). 


Fig.  305. — Passing  the  round-ligament 
forceps  :    First  stage. 


SHORTENING   OF   ROUND  LIGAMENTS    447 

vi.  Closing    the   abdominal    incision. — See    p.    285    and 
Fig.  311. 


Fig.  306. — Passing  the  forceps  :     Second  stage. 


Fig.  307. — Seizing  the  guide  ligature. 


448 


GYNAECOLOGICAL  SURGERY 


Difficulties. — H  the  uterus  is  fixed  by  adhesions  to  the 
pouch  of  Douglas,  these  will  have  to  be  separated  before 


Fig.  308. — Withdrawal  of  the  guide  ligature. 


Fig.  309. — Appearance  of  the  round  ligaments  in  the 
abdominal  wound, 


SHORTENING  OF  ROUND  LIGAMENTS    449 

the  uterus  can  be  brought  forward,  and  diseased  tubes  or 
ovaries,  or  both,  will  have  to  be  removed  in  the  way  de- 
scribed at  p.  476. 

Dangers.  —  As    the    round  -  ligament    forceps    is    being 
passed,  the  uterus  is   steadied   by  traction  on  the  ligature 


Fig.  310. — Anchoring  the 
round  ligament  to  the 
fascia. 


that  has  secured  the  round  ligament,  and  if  too  much 
force  is  employed  the  round  ligament  may  be  torn  away 
from  its  uterine  attachment,  in  which  case  the  uterus  must 
be  fixed  by  ventro-suspension. 

It  would  be  possible  when  forcing  the  forceps  between 
the  peritoneum  and  the  internal  oblique  aponeurosis  to  wound 
some  of  the  large  vessels  about  the  brim  of  the  pelvis,  but 
if  the  forceps  is  passed  fairly  out  of  the  internal  abdominal 

2D 


45o  GYNAECOLOGICAL  SURGERY 

ring  before  it  makes  the  turn  into  the  broad  ligament  no 
force  is  required. 

The  round  ligaments  should  on  no  account  be  anchored 
in  the  middle  line,  as  this  is  always  followed  by  pain. 

Dressing  and  after-treatment. — See  p.   44  and  Chapter 

XXXII. 

III.    INVERSION   OF   THE   UTERUS 

Chronic  inversion  is  rare.     It  can  generally  be   cured 


Fig.  311. — Closing  the  skin-incision. 

with  the  aid  of  an  Aveling's  repositor.  The  failures  when 
this  instrument  is  employed  are  generally  due  to  the 
fact  that  the  cup  of  the  repositor  does  not  fit  the  inverted 
portion  of  the  uterus.  All  uteri  are  not  of  the  same  size. 
It  is  best,  therefore,  to  take  a  cast  of  the  inverted  portion 
by  scooping  out  a  piece  of  yellow  soap,  and  then  have  a 
boxwood  cup  turned  of  the  same  size  and  shape. 

In  rare  cases  Aveling's  repositor,  in  spite  of  every  care, 
fails,  and  an  operation  has  to  be  performed  for  the  cure 
of  the  inversion. 

Many  operations  have  been  proposed,  both  by  the 
abdominal  and  vaginal  route,  including  hysterectomy. 


INVERSION   OF  UTERUS  45* 

We  have  not  had  an  opportunity  of  operating  upon  an 
inverted  uterus,  all  the  cases  we  have  seen  being  cured 
by  the  repositor.  From  an  examination  of  the  literature 
of  the  subject,  Haultain's  operation,  in  which  he  opens 
the  abdominal  cavity  and  incises  the  posterior  wall  of  the 
uterus,  appears  to  us  to  be  the  most  satisfactory.  It  is 
pointed  out  that  the  abdominal  route  has  three  advan- 
tages over  the  vaginal,  because  (i)  the  incision  of  the  uterus 
is  reduced  to  a  minimum  ;  (2)  traction  on  the  round  and 
broad  ligaments  may  help  reposition  ;  (3)  the  uterine  wall 
can  be  more  accurately  sutured  and  haemorrhage  more 
efficiently  controlled. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation.  i.  Opening  the  abdominal  cavity-  —  See 
p.  276.  On  opening  the  abdominal  wall  the  cup-shaped 
depression  is  seen  in  the  uterus. 

ii.  Incising  the  posterior  wall  of  the  uterus. — The 
uterus  is  pulled  up  with  a  volsella,  and  the  posterior 
rim  of  the  cup  incised  through  both  thicknesses  of  the 
inverted  wall. 

iii.  Reposition. — The  inverted  fundus  is  pressed  upon 
from  the  vagina,  and  the  incision  continued  downwards  into 
the  cup  until  the '  inversion  is  completely  reduced  from 
below. 

iv.  Suturing  the  uterine  incision. — The  incision  into 
the  uterus  is  carefully  sutured  with  No.  2  silk  and  all 
haemorrhage  arrested. 

v.  Closing  the  abdominal  cavity- — See  p.  285. 

Dressing   and  after-treatment.— See  p.  44  and  Chapter 

XXXII. 


CHAPTER    XXIII 

OVARIOTOMY 

Indications.  —  Ovariotomy  signifies  the  removal  of  an 
ovarian  tumour,  either  cystic  or  solid,  and  the  presence 
of  an  ovarian  tumour  in  a  patient  is,  with  few  exceptions, 
an  indication  for  its  removal.  Unlike  the  operation  of 
hysterectomy  for  myomata,  concerning  which  there  is 
still  some  diversity  of  opinion  among  gynaecologists,  all 
are  agreed  that  an  ovarian  tumour,  because  of  its  great 
liability  to  complications  and  the  comparative  frequency 
with  which  it  is  malignant,  should  be  removed  at  the 
earliest  convenient  opportunity.  Ovariotomy  is  contra- 
indicated  only  in  cases  in  which  the  general  condition 
of  the  patient  is  so  bad  that  an  operation  would  in  all 
likelihood  cause  her  death.  In  these  cases,  if  the  size 
of  the  cyst  is  increasing  her  distress,  it  should  be  punc- 
tured. Also,  a  small  cyst  well  out  of  the  pelvis  discovered 
at  the  end  of  pregnancy  may  be  allowed  to  remain  till 
the  puerperium  is  well  established. 

Ovariotomy  varies  very  much  in  difficulty.  In  many 
cases  it  is  one  of  the  easiest  major  operations  in  surgery; 
in  others  the  removal  may  tax  the  ingenuity  of  the  most 
experienced  surgeon  or  may  be  altogether  impossible. 

Preparation  of  the  patient- — See  pp.  82-86. 

Instruments. — See  p.  276.  If  the  surgeon  intends  to 
tap  a  cyst  before  removal,  an  ovarian  trocar  may  be  added 
to  the  list  given. 

Operation.  i.  Opening  the  abdominal  cavity.  —  See 
p.  276.  The  size  of  the  opening  will  vary  according  to 
whether  the  tumour  is  cystic  or  solid,  and  whether  the 
operator  intends,  if  the  tumour  is  cystic,  to  tap  its  contents 

452 


Plate  VII.— Multilocular  Ovarian  Adeno-Cystoma  of  the  Left  Side. 


OVARIOTOMY 


453 


before  delivering  it.  In  all  cases  the  incision  should  be 
large  enough  to  insert  the  hand,  so  that  the  complete 
exploration  of  the  surface  of  the  tumour  can  be  effected 
(Fig.  312).  The  practice  of  blindly  tapping  a  presenting 
cyst  through  a  smaller  incision  than  this  is  a  most  un- 
surgical  proceeding  which  is  fraught  with  danger. 

ii.  Tapping  ovarian  cysts. — The  old  custom  of  tapping 
all  ovarian  cysts  before  delivering  them  through  the  abdo- 
minal incision  is  still  practised 
by  many  operators,  their  ar- 
gument being  that,  as  a  rule, 
a  smaller  abdominal  incision 
will  suffice  and  the  risk  of 
subsequent  ventral  hernia  be 
minimized. 

On  the  other  hand,  the  fol- 
lowing points  may  be  urged 
against  this  practice  :■ — • 

(a)  There  are  no  means  of 
diagnosis  of  the  contents  of  an 
ovarian  cyst  until  the  wall  is 
punctured.  The  cyst  may  be 
a  dermoid  and  the  fluid  too 
thick    to     flow     through     the 

trocar.  The  contents  of  an  ovarian  dermoid  are  very  irri- 
tating to  the  peritoneum,  and  extremely  liable  to  cause 
peritonitis.  Or  the  cyst  may  be  malignant,  in  which  case 
some  of  the  papillomatous  growths  escaping  may  become 
attached  to  the  viscera  or  parietes  and  form  secondary 
nodules.  Or,  again,  the  cyst  may  be  glandular  and  its 
colloid  secretion  too  thick  to  flow  through  the  tube,  or 
multilocular,  so  that  the  evacuation  of  all  the  cavities  is 
impossible.  Lastly,  the  cyst  may  be  inflamed  and  contain 
pus. 

(b)  Having  once  plunged  a  trocar  into  a  cyst,  it  is  diffi- 
cult to  prevent  the  fluid  from  oozing  up  by  the  side  of  it, 
and,  if  the  fluid  is  too  thick  to  flow  through  the  trocar,  the 


Fig.  312. — Ovariotomy  : 
Exploring  the  surface 
of  the  cyst. 


454  GYNECOLOGICAL  SURGERY 

cyst  has  to  be  incised  and  the  contents  allowed  to  escape 
or  scooped  out  by  the  hand,  as  may  be,  or  the  attempt 
to  reduce  the  size  before  removal  has  to  be  abandoned, 
after  the  patient  has  been  exposed  to  all  the  risk  due  to 
escape  of  the  cyst-contents. 

(c)  A  further  reason  for  not  tapping  an  ovarian  cyst  is 
that  if  adhesions  are  present  they  will  be  much  more  diffi- 
cult to  separate  from  a  collapsed  cyst-wall  than  from 
one  tightly  stretched. 

(d)  The  most  important  argument  against  routine  tap- 
ping is  the  fact,  now  clearly  established,  that  a  much  larger 
number  of  these  tumours  are  malignant  than  was  formerly 
believed. 

Large  thin-walled  unilocular  cysts  in  young  women,  if 
there  is  no  reasonable  doubt  that  they  are  innocent,  should 
be  tapped,  so  that  a  long  and  unsightly  scar  may  be  avoided. 
In  all  other  cases  it  has  been  our  practice  to  remove  the 
cyst  whole. 

If  the  surgeon  wishes  to  tap  the  cyst,  he  can  do  so  with 
one  of  the  many  ovarian  trocars  now  on  the  market,  or, 
if  a  trocar  is  not  available,  the  cyst-wall  can  be  incised 
with  a  scalpel  and  a  long  piece  of  india-rubber  tubing 
inserted  through  the  hole.  As  the  cyst  empties,  the  collapsed 
wall  may  be  grasped  by  a  special  attachment  on  the  trocar, 
or,  if  there  is  not  one,  by  a  pair  of  ring  forceps,  and  thus 
gradually  drawn  up  through  the  opening,  while  the  assistant 
prevents  as  far  as  possible  any  contents  from  escaping 
into  the  peritoneal  cavity  by  approximating  the  edges  of 
the  wound,  and  further  assists  the  escape  of  the  fluid  and 
the  delivery  of  the  cyst  by  pressing  on  the  sides  of  the 
abdomen  (Fig.  313). 

Precautions. — Before  tapping  one  must  be  satisfied  that 
the  tumour  is  an  ovarian  cyst  and  not  a  pregnant  uterus 
distended  by  hydramnios  or  a  cystic  fibroid.  These  mis- 
takes have  been  made  on  occasion  with  disastrous  results. 
If,  from  the  appearance  of  the  cyst-wall,  the  operator  has 
reason  to   suspect  that  he  has  to  do  with   a  dermoid,   a 


OVARIOTOMY 


455 


suppurating  or  a  malignant  cyst,  the  tumour  should  not 
be  tapped.  The  wall  of  a  benign  ovarian  cyst  resembles 
mother-of-pearl  in  appearance  ;  if,  therefore,  the  tumour 
is  dull,  discoloured,  bossy,  or  has  papillomatous  growths 
attached  to  it,  it  should  be  delivered  whole. 

Lastly,    before    tapping    a    cyst,    the    operator    should 


Fig  313. — Tapping  the  cyst. 


make  sure,  by  passing  the  fingers  over  its  upper  surface, 
that  there  are  no  adhesions  in  this  situation  ;  if  there  are, 
and  he  taps  the  cyst  before  separating  them,  he  will  not 
be  able  to  draw  it  up  out  of  the  wound. 

When  tapping,  the  operator  should  push  the  trocar 
gently  through  the  cyst-wall  while  his  assistant  supports 
the  tumour  on  each  side  (Fig.  313).  If  it  is  necessary 
to  puncture  secondary  cysts,  care  must  be  taken  not  to 
force  the  point  of  the  instrument  through  the  main 
cyst-wall. 

iii.  Delivery   of  the   tumour. — Supposing    it    has    been 


456 


GYNECOLOGICAL  SURGERY 


decided,  for  the  time  being  at  any  rate,  not  to  tap  the 
cyst,  and  always  in  the  case  of  a  solid  ovarian  tumour, 
the  abdominal  incision  is  extended  to  a  length  requisite 
for  the  removal  of  the  tumour  whole.  If  free  of  adhesions, 
the  tumour  is  gently  lifted  up  in  the  hollow  of  the  hand, 
palmar  surface  uppermost,  through  the  abdominal  wound, 

the  cut  ends 
of  which  are 
retracted.  On 
its  delivery 
the  tumour 
is  handed  to 
the  assistant, 
who  will  take 
special  care 
not  to  drag 
on  the  pedi- 
cle, since  in 
some  cases 
this  may  be 
so  thin  or  so 
rotten  that 
the  slightest 
strain  will 
rupture  it, 
with  the  re- 
sult that  the  distal  end  will  slip  down  into  the  pelvis 
and  brisk  haemorrhage  result  before  it  can  be  secured 
as  described  below. 

iv.  Treatment  of  the  pedicle.  —  The  pedicle  of  an 
ovarian  tumour  consists  of  the  ovarian  artery,  the  pampini- 
form plexus  of  veins,  the  ovarico-pelvic  and  ovarico-uterine 
ligaments,  with  that  portion  of  the  broad  ligament  between 
these  structures,  and  frequently  the  Fallopian  tube.  The 
operator,  holding  this  pedicle  between  the  fingers  and 
thumb  of  his  left  hand,  transfixes  it  above  them  with  a 
curved  needle  armed  with  24  in.  of  No.  4  silk,  so  arranged 


Fig.  314. — Delivering  a  multilocular  cyst. 


Plate  VIII.— Ovarian  Dermoid  Cyst. 


OVARIOTOMY 


457 


that  there  are  12  in.  on  each  end  of  the  eye,  care  being 
taken  to  avoid  the  plexus  of  veins  (Fig.  315).  The  loop  of 
the  ligature  is  now  cut  with  a  pair  of  scissors  so  that  two 
ligatures  are  obtained,  and  the  pedicle  can  then  be  firmly 
secured  in  two  halves  by  these  ligatures,  care  being  exercised 
to  take  hold  of  the  corresponding  ends  of  the  ligatures  when 
tying  them  (Fig.  316).     A  third  encircling  ligature  is  lastly 


Fig.  315. — -Transfixing  the  pedicle. 

applied  to  the  whole  pedicle  in  the  sulcus  made  by  the  other 
ligatures,  thus  securing  any  veins  which  may  have  escaped 
the  primary  ligatures.  During  the  ligation  the  assistant 
must  hold  the  tumour  so  that  the  pedicle  hangs  loose. 

The  tumour  is  now  removed  by  cutting  through  the 
pedicle  with  scissors  at  least  half  an  inch  above  the  ligatures, 
for  if  the  point  of  severance  be  too  near  the  ligatures  the 
stump  may  retract  and  slip  (Fig.  317).  The  stump  is  then 
swabbed,  and  if  it  remains  blanched,  and  there  is  no  oozing, 
the  ligatures  are  cut  short  and  it  is  allowed  to  fall  back 
into  the  abdomen. 

Variations  in  treatment  of  the  pedicle. — The  method  of 


458  GYNECOLOGICAL  SURGERY 


Fix  316. — Ligaturing  the  pedicle  in  halves. 


Fig.  317, — Removing  the  cyst. 


OVARIOTOMY 


459 


ligaturing  the  stump  given  above  is  simple,  and,  when 
properly  carried  out,  quite  satisfactory  for  thin  pedicles,  but 
some  of  the  other  methods  described  elsewhere  (pp.  38-41) 
are  equally  effective.  The  pedicle  at  times  is  so  broad 
that  there  would  be  great  danger  of  its  slipping  if  it  were 
only  ligatured    in    halves,   and    in    these    circumstances  a 


Fig.  318. — Ovariotomy :  Alternative  method  of  treating 
the  pedicle  :    Applying  the  clamps. 

chain  of  three,  four,  or  more  ligatures  may  be  applied, 
according  to  the  directions  given  at  p.  41.  The  pedicle 
may  be  so  short  and  the  tumour  so  large  that  there  is  a 
difficulty  in  properly  securing  the  pedicle  before  the  removal 
of  the  tumour.  Under  these  conditions  it  is  best  to  clamp 
the  pedicle  first  with  a  couple  of  pairs  of  forceps,  remove 
the  tumour,  and  afterwards  ligature  it  below  the  forceps 
(Figs.  318  and  319). 

After  removing  an  ovarian  cyst  the  other  ovary  should 
be  examined  also,  lest  it  be  diseased,  and  in  the  case  of 


460  GYNECOLOGICAL  SURGERY 

papillomatous  ovarian  cysts  many  authorities  recommend 
the  removal  of  the  opposite  ovary,  even  if  it  appear  healthy, 
because  statistics  show  that  two-thirds  of  malignant  papil- 
lomatous cysts  of  the  ovary  are  bilateral. 

Dressing  and  after-treatment — See  p.  44  and  Chapter 

XXXII. 

Difficulties,     i.  Delivering    the    tumour. — Ovarian    cysts 


Fig.  319. — Ligaturing  the  pedicle. 

are  very  liable  to  become  inflamed  owing  to  torsion  of  the 
pedicle,  pressure,  the  nature  of  their  contents  (dermoids) 
or  other  causes,  and  as  a  consequence  the  cyst  may  become 
adherent  to  intestines,  omentum,  bladder,  rectum,  to  the 
large  blood-vessels,  to  the  floor  of  the  pelvis  or  the  abdo- 
minal parietes,  and  to  the  diaphragm.  If  adhesions  are 
present,  it  will  be  dangerous  and  perhaps  impossible  to 
deliver  the  tumour  before  they  are  separated,  and  for 
this  reason  great  care  must  be  taken  that  any  adhesions 
on  the  under-surface  are  detected,  otherwise  they  may  be 


Plate  IX. — Bilateral  Papuliferous  Ovarian  Cysts. 


OVARIOTOMY  461 

torn  through,  and  if  attached  to  veins  great  haemorrhage 
may  immediately  occur.  Adhesions  can  be  separated  by 
the  hand,  swabs,  scissors,  or  scalpel.  Parietal  adhesions  or 
adhesions  to  the  floor  of  the  pelvis  are,  as  a  rule,  best  sepa- 
rated by  gently  insinuating  the  hand  between  the  cyst- 
wall  and  the  peritoneum.  In  tying  off  omental  adhesions 
the  operator  must  avoid  including  a  portion  of  the  trans- 
verse colon  running  in  the  omentum.  When  the  intestine 
is  adherent  to  the  cyst  and  an  endeavour  is  being  made  to 
dissect  it  off,  the  wall  of  intestine  must  be  clearly  identified, 
since  the  two  are  sometimes  so  intimately  attached  and  the 
intestine  is  so  spread  out  that  it  is  quite  easy  to  mistake 
the  tissues  and  open  the  bowel.  Part  of  the  cyst  may  also 
be  impacted  in  Douglas's  pouch,  in  which  case  care  must 
be  taken  not  to  rupture  it  during  its  delivery. 

ii.  Restraint  of  the  intestines. — In  some  cases  in  which 
the  tumour  is  very  large  and  the  incision  in  the  abdominal 
parietes  extensive,  the  biggest  swab  will  not  be  sufficient 
to  keep  the  bowels  in  position  after  the  tumour  is  delivered. 
This  difficulty  can  be  surmounted  by  drawing  together  that 
part  of  the  incision  above  the  umbilicus  with  one  or  two 
temporary  silk  sutures  passing  through  all  the  layers  of 
the  abdominal  wall. 

iii.  Closing  the  abdominal  cavity- — See  p.  285. 
Irremovable  ovarian  cysts. — It  sometimes  happens  that 
while  the  removal  of  an  adherent  ovarian  tumour  at  first 
seemed  feasible,  the  surgeon  after  a  while  finds  that  the 
successful  termination  of  the  operation  is  hopeless.  Under 
these  conditions  two  courses  are  open  to  him  :  either 
(a)  to  empty  the  cyst  of  its  contents  and  then  stitch  the 
hole  to  the  abdominal  opening,  thus  making  the  cyst- 
cavity  extraperitoneal  and  draining  it ;  or,  (b)  when  the 
cyst  fills  a  very  large  portion  of  the  abdominal  cavity 
and  is  universally  and  indissolubly  adherent,  deliberately 
to  sequester  the  cyst  by  closing  the  incision  in  its  wall 
and  the  parietes,  and,  except  for  the  evacuation  of  its 
contents,  leave  the  patient  in  statu  quo. 


462  GYNAECOLOGICAL  SURGERY 

If  the  cyst  is  rendered  extraperitoneal  and  drained,  it 
sometimes  happens  that,  after  a  period  of  prolonged  dis- 
charge, the  patient  recovers  owing  to  the  destruction  of 
the  secretory  surface  produced  by  the  inflammation  of 
the  cyst-wall  that  always  follows  drainage.  In  other 
cases,  however,  great  suppuration  and  necrosis  of  the 
cyst-wall  ensue,  to  which  the  patient  succumbs. 

If  the  cyst  has  been  sequestered  it  will  gradually  "refill 
and  require  subsequent  tapping.  It  is  most  important, 
therefore,  for  the  surgeon  carefully  to  consider,  when 
dealing  with  an  adherent  cyst,  whether  there  is  a  fair 
chance  of  being  able  to  remove  it  ;  if  he  concludes  that 
there  is  not,  he  had  better  treat  it  by  one  of  the 
methods  just  described  than  endeavour  to  remove  it,  lest 
in  the  attempt  he  inflict  such  injuries  on  the  mesentery, 
bowel,  or  large  abdominal  veins  that  the  patient  succumbs. 
Nothing  requires  more  experience  or  wiser  judgment  in 
abdominal  surgery  than  to  decide  when  not  to  interfere 
with  an  ovarian  cyst. 

Hysterectomy  and  ovariotomy. — In  cases  of  papilloma- 
tous or  obviously  malignant  cysts  or  solid  tumours  of  both 
ovaries,  or  even  in  cases  where  malignancy  may  be  reasonably 
suspected,  it  is  advisable  to  remove  the  uterus  in  addition. 
Hysterectomy  may  also  be  occasionally  necessary  in  order 
to  arrest  haemorrhage  or  to  facilitate  the  removal  of  adherent 
ovarian  tumours.  At  times,  myomata  of  the  uterus  may 
co-exist  with  an  ovarian  cyst  or  cysts.  If  only  one  ovary 
has  to  be  removed,  an  endeavour  should  be  made  to  enu- 
cleate the  myoma,  if  feasible.  If  both  ovaries  have  to  be 
removed,  the  conservation  of  the  uterus  is  not  necessary. 


CHAPTER    XXIV 
OPERATIONS   ON  THE    BROAD    LIGAMENT 

I.    ENUCLEATION    OF    A   BROAD-LIGAMENT    CYST 

General  characteristics.  —  All  broad-ligament  cysts  have 
certain  general  characteristics,  namely,  the  Fallopian  tube 
is  stretched  over  them,  they  are  covered  with  shiny  peri- 
toneum, and,  except  those  growing  from  the  outer  third 
of  the  mesosalpinx,  they  have  no  pedicle. 

The  relations  of  a  broad-ligament  cyst  are  very  variable, 
and  depend  upon  the  site  of  its  origin  and  its  size. 

These  cysts  may  start  in  three  different  positions,  as 
follows  : — 

i.  In  the  mesosalpinx. 

2.  Between  the  ovarian  and  uterine  arteries  in  the 

broad  ligament. 

3.  Under  the  uterine  arteries. 

1.  When  growing  from  the  inner  two-thirds  of  the 
mesosalpinx  the  cysts  are  sessile ;  when  from  the  outer 
third,  pedunculated.  The  ovarian  vessels  in  either  case 
lie  on  the  deep  surface  of  the  cyst.  Such  tumours  can, 
therefore,  be  removed  without  wounding  the  ovarian 
artery,  are  accessible,  and,  except  for  adventitious  adhe- 
sions, are  easily  dealt  with. 

2.  If  the  cyst  starts  between  the  ovarian  and  uterine 
vessels,  it  forces  its  way  upwards  until  the  ovarian  vessels 
and  Fallopian  tube  lie  sessile  on  its  upper  surface  and  in 
close  relation  with  each  other,  the  vessels  often  being 
spread  out. 

At  a  later  stage  the  tumour  grows  backwards,  progres- 
sively stripping  the  peritoneum  and  ureter  from  off  the 
lateral  pelvic  wall  so  that  the  posterior  layer  of  the  broad 

463 


464  GYNECOLOGICAL  SURGERY 

ligament  is  gradually  displaced  towards  the  opposite  side 
and  in  time  the  pouch  of  Douglas  is  entirely  obliterated. 
When  this  happens,  adhesion  occurs  between  the  contiguous 
peritoneal  surfaces  covering  the  cyst,  the  back  of  the  uterus, 
and  the  opposite  broad  ligament.  During  this  process  the 
cyst  makes  its  way  between  the  layers  of  the  meso-sigmoid 
and  underneath  the  peritoneum  covering  the  rectum  until 
the  bowel  comes  to  lie  sessile  on  its  upper  and  inner  surface. 
The  relation  of  the  ureter  and  the  iliac  vessels  to  such  a 
cyst  is  most  important.  The  ureter  lies  on  its  inner  surface 
closely  attached  to  the  peritoneum,  while  the  iliac  vessels 
are  on  its  outer  side. 

3.  If  the  cyst  starts  below  the  uterine  vessels,  these,  as 
well  as  the  ovarians,  run  across  on  its  upper  surface,  as 
does  also  the  ureter.  These  cysts,  if  they  attain  a  large 
size,  cross  the  middle  line  under  the  peritoneum  at  the 
bottom  of  Douglas's  pouch,  which  is  obliterated  from 
below  upwards  as  the  peritoneum  is  forced  off  the  posterior 
surface  of  the  uterus.  The  general  displacement  of  the 
parts  is  very  similar  to  that  which  obtains  in  the  preceding 
variety,  but  is  distinguishable  by  the  position  of  the  uterine 
vessels  and  ureter.  The  second  and  third  varieties  of  these 
cysts  at  times,  by  crossing  the  middle  line,  give  the  appear- 
ance of  involving  both  broad  ligaments.  The  anatomical 
displacements  are  so  varied  and  intricate  that  no  two 
cysts  have  exactly  the  same  relations,  and  a  very  careful 
inspection  of  the  tumour,  with  reference  to  the  points  we 
have  mentioned,  should  first  be  undertaken  before  its 
removal  is  commenced. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation.  i.  Opening  the  abdominal  cavity. — See 
p.  276.  On  passing  the  hand  into  the  peritoneal  cavity  to 
ascertain  the  relations  of  the  cyst,  the  operator  will  discover 
that  the  tumour  has  no  pedicle,  and  that  it  cannot  be 
delivered.  On  examining  its  upper  surface,  the  capillary 
vessels  of  the  stretched  peritoneum  are  seen,  together  with 


Plate  X. — Bilateral  Malignant  Ovarian  Tumour. 


BROAD-LIGAMENT  CYST 


465 


the  Fallopian  tube,  running  across  it,  and  in  the  case  of 
the  second  and  third  varieties  the  ovarian  vessels  or  ovarian 
and  uterine  vessels  as  well. 

ii.  Incising  the  broad  ligament. — At  a  spot  on  the 
surface  of  the  cyst  where  blood-vessels  appear  least  numerous, 
the  broad  ligament  is  opened  by  gently  incising  with  a 
scalpel  the  layer  of  peritoneum  covering  the  cyst  (Fig.  320). 


Fig,  320. — Enucleation  of  a  broad-ligament  cyst :    Incising 
the  broad  ligament. 

If  this  incision  is  made  too  deeply  the  cyst-wall  will 
be  wounded,  the  contents  escape,  and  as  a  result  much 
greater  difficulty  will  be  experienced  in  removing  the  cyst. 

iii.  Enucleation. — -The  opening  in  the  broad  ligament 
is  now  sufficiently  enlarged  with  the  fingers,  and  by  their 
means,  aided  by  the  handle  of  a  scalpel  or  by  scissors,  as  may 
be  most  convenient,  the  cyst  is  shelled  out.     During  this 

2E 


466 


GYNECOLOGICAL  SURGERY 


proceeding  the  path  of  least  resistance  should  be  followed, 
but  keeping  as  near  to  the  cyst-wall  as  possible,  so  as  to 
avoid  tearing  the  broad  ligament  or  damaging  any  other 
important  structures  (Fig.  321).  Any  bleeding  spots  are 
caught  with  forceps  for  the  time  being,  and  can  later  be 
ligatured  with  No.  4  silk. 

If  the  tumour  is  very  large,  it  may  be  convenient,  having 
opened  the  broad  ligament,  to  tap  the  cyst  before  attempting 
its  enucleation. 

Closing    the    cavity    in    the    broad    ligament.  —  All 


IV. 


Fig.  321. — Enucleating  the  cyst. 


oozing  of  blood  having  been  stopped,  and  all  redundant 
peritoneum  having  been  cut  away  with  scissors,  it  will 
often  be  found  that  the  cavity  from  which  the  cyst  was 
removed  is  so  much  diminished  that  its  obliteration  can 
be  sufficiently  effected  by  a  continuous  suture  approximat- 
ing the  edges  of  the  peritoneum  (Fig.  322).  Where,  how- 
ever, the  cavity  extends  deeply  into  the  depths  of  the 
broad  ligament,  and  much  oozing  from  its  walls  is  taking 
place,  it  may  be  obliterated  as  follows  :  A  curved  needle 
armed  with  a  long  piece  of  No.  2  silk  transfixes  the  tissue 
at  the  bottom  of  the  cavity,  and  the  end  of  the  suture  is 
tied.     The  cavity  is  then  gradually  obliterated  from  below 


BROAD-LIGAMENT  CYST 


467 


upwards  by  suturing  the  walls  together,  and  so  gradually 
approximating  the  two  layers  of  the  broad  ligament  till 
the  free  edges  of  this  structure  are  reached,  when  they  are 
carefully  sutured. 

If  a  large  cavity  is  left  unobliterated  there  is  consider- 
able risk  of  postoperative  oozing  taking  place  therein,  and 
the  hematoma  so  formed  may  give  rise  to  much  inflamma- 
tory trouble. 

The  steps  of  the  enucleation  just  described  will  be  the 


Fig.  322. — Closing  the  cavity  in 
the  broad  ligament. 

same,  mutatis  mutandis,  when  removing  any  other  tumour 
that  has  distended  the  broad  ligament,  such  as  a  broad- 
ligament  myoma,  or  the  mass  formed  by  a  tubal  gestation 
that  has  ruptured  into  the  broad  ligament. 

v.  Closing  the  abdominal  cavity. — See  p.   285. 

Dangers,  i.  Haemorrhage. — -More  blood  must  of  neces- 
sity be  lost  during  the  enucleation  of  a  broad-ligament 
cyst  than  in  removing  a  simple  ovarian  tumour,  but,  as  a 
rule,  the  oozing  from  the  walls  of  the  broad  ligament  is 
of  no  serious  consequence,  although  occasionally  it  may 
be  so  severe  as  to  necessitate  special  treatment. 


468  GYNAECOLOGICAL  SURGERY 

If  the  ovarian  vessels  are  stretched  out  over  the  surface 
of  the  tumour,  it  is  often  better,  before  enucleating  the 
cyst,  to  ligature  them  at  their  uterine  and  pelvic  ends 
and  divide  them.  Sometimes  the  cyst  will  be  easily  enu- 
cleated till  the  operator  gets  to  its  base,  when  he  finds  that 
it  is  held  by  some  tough  structures,  generally  uterine 
vessels,  which,  if  cut  without  previous  clamping  with 
forceps,  may  give  rise  to  troublesome  bleeding. 

Lastly,  the  bleeding  from  the  bed  of  the  cyst  is  at 
times  too  free  to  allow  of  the  closure  of  the  cavity,  for  fear 
of  blood  subsequently  collecting.  If  there  is  any  danger 
of  this,  the  peritoneal  capsule  of  the  cyst  must  be  sutured 
to  the  abdominal  wound  so  that  the  cavity  becomes  extra- 
peritoneal ;  the  cavity  is  then  packed  with  gauze,  and 
drained. 

ii.  Injury  to  ureter  or  large  veins.  — ■  It  very  often 
happens  that  after  a  cyst  has  been  enucleated  the  ureter 
will  be  seen  lying  across  the  base  of  the  broad  ligament, 
and  the  operator  must  always  have  in  his  mind  the  danger 
of  wounding  this  structure  when  he  is  enucleating,  as  the 
ureter  may  be  displaced  from  its  natural  position,  and  has 
been  found  running  over  the  cyst.  It  can  be  recognized 
as  a  long  tube  about  the  size  of  a  slate  pencil,  and  if  it  is 
carefully  inspected  for  a  few  moments  lumbricoid  muscular 
contractions  may  be  seen  to  take  place  in  it. 

When  the  cyst  is  very  large  it  may  spread  over  the 
brim  of  the  pelvis,  in  which  case  the  iliac  arteries  and  veins 
will  lie  under  its  base  and  may  be  wounded. 

Dressing  and  after-treatment. — See  p.  44  and  Chap.  xxxn. 

Alternative  methods  of  treating  broad-ligament  cysts. 
— It  is  not  always  possible  to  enucleate  the  cyst  owing  to 
the  adhesions  between  it  and  the  cellular  tissue  of  the  broad 
ligament.  In  these  circumstances  it  is  sometimes  possible 
to  excise  the  cyst  together  with  the  portion  of  the  broad 
ligament  in  which  it  grows,  especially  when  it  is  one  of 
those  growing  between  the  layers  of  the  mesosalpinx.  The 
cyst  should  be  completely  emptied  by  puncture,  and  the 


Plate  XI. — Broad- Ligament  Cyst  of  the  Left  Side. 


BROAD-LIGAMENT  CYST 


469 


collapsed  sac,  together  with  that  portion  of  the  broad 
ligament  covering  it,  is  then  pulled  up  out  of  the  wound 
(Fig.  323).  The  position  of  the  ureter  having  been  defined  as 
far  as  possible,  the  ovarico-pelvic  ligament  is  clamped,  as  is 
the  uterine  end  of  the  broad  ligament  and  Fallopian  tube, 
and  the  tissue  between  the  clamps  excised  by  a  wedge- 
shaped  incision.  In  many  cases  it  is  possible  to  remove 
the  entire  cyst  in  this  way,  but  sometimes  a  small  piece  of 


Fig.  323, — Excision  of  a  broad-ligament  cyst  :    Applying 
clamps  to  the  base  of  the  collapsed  cyst. 

its  lower  part  is  left  behind.  This,  however,  in  our  experience 
does  not  give  trouble,  the  sac  probably  becoming  oblite- 
rated as  after  a  partial  excision  of  the  tunica  vaginalis  for 
hydrocele.  The  two  ends  of  the  ovarian  vessels  having  been 
secured,  the  cut  edges  of  the  incision  in  the  broad  ligament 
are  united  by  interrupted  mattress-sutures  (Fig.  324). 

The  ovary  may  or  may  not  have  to  be  removed  during 
this  operation.  If  possible,  it  should,  of  course,  be  con- 
served. 

In  those  very  formidable  broad-ligament  cysts  which 
comprise  the  second  and  third  varieties  described,  it  is 
frequently    impossible    to    remove    the    cyst    in    any    way 


470 


GYNAECOLOGICAL  SURGERY 


without  the  gravest  danger  of  wounding  the  ureter,  bowel, 
and   large  vessels.      In   these   circumstances   the   cyst-wall 


Fig.  324. — Ligaturing  the 

cut  edges   of  the   broad 

ligament. 

must  be  brought  up  to  the  abdominal  incision  and  stitched 
to  it,  so  that  it  becomes  extraperitoneal.     The  cyst  is  then 


Fig.  325. — Treatment  of  an  irremovable  broad-ligament 
cyst :  Stripping  the  peritoneum  off  the  upper  surface 
of  the  cyst  before  partial  excision. 


PSEUDO-BROAD-LIGAMENT  CYST        47* 

packed  lightly  with  gauze  and  drained,  or,  after  being 
emptied,  the  hole  may  be  sewn  up  and  the  cyst 
sequestered  (p.  461). 

In  other  cases  a  certain  amount  of  cyst-wall  can  be 
removed  but  not  all  (Fig.  325).  This  having  been  done, 
the  edges  of  the  remaining  portion  must  be  sutured  to  the 
abdominal  wound  and  the  cavity  drained  (Fig.  326). 


II. 


Fig.  326. — Stitching  the  remainder  of  the  cyst  to  the 
abdominal  wound. 

REMOVAL   OF   A   PSEUDO-BROAD-LIGAMENT 
CYST 


By  a  pseudo-broad-ligament  cyst  we  mean  an  ovarian 
cyst  which,  instead  of  rising  up  out  of  the  pelvis,  has  grown 
downwards  and  forwards  under  the  posterior  layer  of  the 
broad  ligament,  pushing  and  rotating  the  anterior  layer  of 


472  GYNECOLOGICAL  SURGERY 

this  structure  upwards  and  practically  forming  a  covering 
to  the  ovarian  cyst,  so  that  on  the  abdomen  being  opened 
the  appearance  presented  resembles,  to  the  inexperienced 
eye,  that  of  a  broad-ligament  cyst.  Consequently,  much 
time  and  trouble  are  expended  in  trying  to  enucleate  the 
tumour. 

These  cysts  may  be  identified  by  noting  that  the  ovary 
is  not  separate  from  the  tumour,  and  that  while  the 
anterior  surface  of  the  cyst  is  covered  by  the  stretched 
peritoneum  of  the  broad  ligament,  with  the  Fallopian  tube 
and  ovarian  vessels  running  across  it,  the  cephalward  and 
posterior  surface  present  the  characteristics  of  an  ordinary 
ovarian  cyst.  If  the  hand  is  passed  down  into  the  pelvis 
at  the  back  of  the  cyst,  it  will  in  many  cases  be  found 
possible  to  scoop  it  out  from  under  the  stretched  and 
rotated  broad  ligament,  and  subsequently  to  deal  with 
it  by  the  method  of  removal  previously  described.  When 
it  is  very  tightly  incarcerated  under  the  broad  ligament, 
and  particularly  if  it  is  very  adherent,  the  following  method 
should  be  adopted  : — ■ 

Operation.  i.  Opening  the  abdominal  cavity.  —  See 
p.  276. 

ii.  Dividing  the  broad  ligament.  —  The  edge  of  the 
stretched  broad  ligament,  which  can  be  identified  by 
the  Fallopian  tube,  should  be  defined  and  separated  from 
the  upper  surface  of  the  cyst.  A  pair  of  pressure-forceps 
is  now  applied  in  the  neighbourhood  of  the  uterus,  and 
another  about  an  inch  externally  to  it  ;  each  of  these 
should  include  the  leash  of  ovarian  vessels  which  is  seen 
running  over  the  surface  of  the  tumour  (Fig.  327).  The 
broad  ligament  covering  the  tumour  is  then  divided  with 
scissors  as  far  as  the  pedicle  of  the  tumour,  i.e.  the  hilum 
of  the  ovary,  which  forms  the  limit  of  separable  attach- 
ment between  the  broad  ligament  and  the  upper  surface 
of  the  tumour  (Fig.  328). 

iii.  Delivering  the  tumour. — The  surgeon  places  his  left 
hand  underneath  the  tumour,  now  freed  from  the  tethering 


PSEUDO-BROAD-LIGAMENT   CYST        473 

broad  ligament,  and  gradually  levers  it  up  and  delivers  it 
through  the  abdominal  incision  (Fig.  329). 


Fig.  327. — Removal    of  a  pseudo-broad-ligament    cyst  : 
Clamping  the  stretched  broad  ligament. 

iv.  Tying   the  ovarian   pedicle. — The    pedicle    is    trans- 
fixed with  No.  4  silk,  and  that  portion  of  it  nearest  the 


Fig.  328. — Dividing  the  stretched  broad  ligament. 

uterus  is  secured,  the  assistant  at  the  same  time  pulling 
into  the  grasp  of  the  ligature  the  inner  half  of  the  previously 


474  GYNAECOLOGICAL  SURGERY 


Fig.  329. — Delivering  the  cyst. 


Fig.  330. — Ligaturing  the  inner  half  of  the  pedicle. 


PSEUDO-BROAD-LIGAMENT  CYST 


475 


divided  broad  ligament  (Fig.  330).  After  this  the  cyst  is 
raised  right  up  by  the  assistant,  and  the  other  half  of 
the  ligature  is  tied  similarly,  including  the  outer  half 
of  the  cut  broad  ligament,  and  the  cyst  is  then  cut  away 
(Fig.  331) 


Fig.  331. — Ligaturing  the  outer  half  of  the  pedicle. 

v.  Closing  the  abdominal  cavity. — See  p.  285. 

Dangers. — The  dangers  are  similar  to  those  of  ordinary 
ovariotomy  (p.  460).  It  should  be  remembered  that  the 
ureter  lies  on  the  outer  side  of  such  cysts  ;  not  on  the  inner, 
as  in  a  true  broad-ligament  cyst. 

Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 


CHAPTER   XXV 

OPERATIONS    ON   THE    FALLOPIAN   TUBES 
AND    OVARIES 

I.  SALPINGO-OOPHORECTOMY 
Indications. — A  Fallopian  tube  and  ovary  may  be  excised 
either  through  an  opening  in  the  abdominal  wall  or  through 
one  in  the  vaginal  wall.  In  our  opinion,  the  first  method 
is  the  safer  and  more  satisfactory,  and  this  we  shall  now 
proceed  to  describe.  The  appendages  may  be  removed 
for  diseases  of  the  tubes  and  ovaries,  such  as  acute 
and  chronic  salpingitis,  hydro-salpinx,  pyo-salpinx,  hsemato- 
salpinx,  tubo-ovarian  cyst  and  abscess,  and  carcinoma 
of  the  tube,  or  for  tubal  gestation.  They  are  removed  by 
some  to  hasten  the  menopause  in  bleeding  myomata,  or  to 
cure  dysmenorrhcea,  all  other  means  having  failed.  They 
have  also  been  removed  for  epilepsy,  and  to  check  the" 
growth  of  mammary  carcinoma. 

The  operation  of  salpingo-oophorectomy  has  in  the  past 
been  much  abused,  owing  to  its  being  performed  in  cases 
in  which  a  salpingectomy  would  have  sufficed.  The  reasons 
for  and  against  conserving  the  ovary  will  be  discussed 
at  the  end  of  this  chapter.  For  the  present  we  limit  our- 
selves to  stating  that  the  ablation  of  a  healthy  ovary 
merely  to  increase  the  facility  of  removing  a  diseased  tube 
is  absolutely  unjustifiable. 

The  operation  is  most  often  indicated  in  those  cases  of 
inflammatory  disease  of  the  tube  secondarily  involving  the 
ovary  in  which  both  structures  are  destroyed  beyond 
the  reach  of  conservative  surgery ;  in  tubal  gestation  in 
which  the  ovary  is  involved;  and  in  ovarian  gestation 
in  which  the  tube  is  damaged.      The  method  of  treating 

476 


SALPINGO-OOPHORECTOMY  477 

uterine  myomata  by  salpingo-oophorectomy  is  altogether 
to  be  condemned,  since  it  sacrifices  healthy  organs  in  the 
possession  of  which  all  the  attributes  of  femininity  centre, 
for  one  which,  in  addition  to  being  functionally  useless,  is 
a  menace  to  health  and  life. 

As  a  method  of  treating  dysmenorrhcea  it  is  very  rarely 
indicated.  It  has  been  advocated  in  cases  of  intractable  so- 
called  "ovarian"  dysmenorrhcea;  and  undoubtedly,  if  the 
pain  can  be  definitely  proved  to  be  located  in  the  ovaries, 
the  removal  of  these  organs  would  be  a  logical  procedure 
to  relieve  it.  We  are,  however,  unacquainted  with  any 
recorded  case  in  which  monthly  attacks  of  ovarian  pain 
recurred  after  the  removal  of  the  body  of  the  uterus, 
and  our  belief  is,  therefore,  that  the  pain  in  all  or  almost 
all  cases  of  dysmenorrhcea  is  of  uterine  origin.  If  so,  sub- 
total hysterectomy,  not  oophorectomy,  is  the  proper  opera- 
tion in  cases  of  this  class. 

We  have  no  experience  of  the  operation  as  a  treatment 
for  epilepsy.  Some  successful  cases  have  been  recorded, 
but,  on  the  whole,  we  judge  that  it  has  been  a  failure. 

Salpingo-oophorectomy  has  been  performed  many  times 
with  the  idea  of  checking  the  growth  in  inoperable  mammary 
carcinoma.  While  the  results  on  the  whole  have  been 
disappointing,  a  certain  number  of  cases  of  undoubted 
amelioration  or  actual  disappearance  of  the  growth  are  on 
record.  It  is,  therefore,  a  perfectly  justifiable  operation  if 
the  patient,  fully  understanding  its  dubious  chances  of 
success,  desires  it. 

When  the  appendages  are  adherent,  the  operation  may 
become  one  of  the  most  difficult  in  surgery  ;  in  fact,  in 
exceptional  cases  so  firm  may  the  adhesions  be  that  the 
operation  has  to  be  abandoned.  Taking  a  double  pyo- 
salpinx  of  average  size  as  an  example,  the  operation  is 
performed  as  follows  : — 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation,     i.  Opening  the  abdominal  cavity. — See  p.  276. 


478 


GYNAECOLOGICAL  SURGERY 


ii.  Defining  the  appendages. —  The  left  hand  of  the 
operator  is  passed  through  the  incision  and  the  condition 
of  the  pelvis  explored.  In  this  proceeding  the  fundus  of 
the  uterus  should  be  first  identified. 

After  the  peritoneal  cavity  has  been  opened,  instead 
of  the  intestines  slipping  back  so  as  to  disclose  the 
pelvic  organs,  all  that  the  operator  sees  is  either  the 
omentum  with  its  lower  edge  fixed  in  the  region  of  the 
pubes,   forming    a    lid    to    the    pelvic    cavity,    or  coils   of 


Fig.  332. — Salpingo-oophorectomy  : 
Separating  adherent  omentum. 

intestine  matted  together  and  fixed  in  the  same  position. 
On  passing  his  hand  into  the  abdominal  cavity,  he  will 
perhaps  find  that  the  omentum  or  intestine  is  adherent 
to  the  abdominal  parietes  or  to  the  fundus  of  the  bladder, 
or  that  some  coils  of  small  intestine  are  adherent  to  the 
anterior  surface  of  the  uterus  or  to  the  Fallopian  tubes. 
The  pelvic  colon  is  almost  invariably  adherent  by  its 
appendices  epiploic^  to  the  diseased  appendages,  par- 
ticularly on  the  left  side. 

If  any  omental  bands  are  present,  these  should  first 
be  clamped  with  forceps,  divided  and  tied  (Fig.  332).  The 
more  superficial  of  the  intestinal  adhesions  are  then  care- 
fully separated  (Fig.  333). 


Plate  XII. — Bilateral  Hydro- Salpinx. 


SALP1NGO-OOPHOREGTOMY 


479 


In  many  cases  the  appendix  will  be  found  adherent 
to  the  Fallopian  tube  on  the  right  side,  in  which  case  it 
should  be  carefully  separated,  and  if  its  condition  warrants 
removal  this   may  be    carried   out   as  described  elsewhere 

(P-  524)- 

iii.  Insertion  of  the  large  swab. — The  large  swab  is 
now  to  be  inserted  (p.  293),  and  the  separation  of  the  deeper 
and  more   formidable   adhesions   may   then   be   proceeded 


Fig.  333. — Separating 
adherent  intestine. 


with,  without  fear  of  infection  of  the  general  peritoneal 
cavity  in  the  event  of  the  tube  rupturing. 

iv.  Separation  of  the  appendages. — This,  of  course,  is 
carried  out  first  on  one  side  and  then  on  the  other.  Which 
appendage  is  first  removed  may  be  a  matter  of  little 
consequence,  but  if  that  of  one  side  is  obviously  easier 
to  remove  than  that  of  the  other,  then  it  should  be 
dealt  with  first,  in  order  that  additional  room  may  be 
available  for  the  removal  of  the  more  adherent  one. 

The  dilated  tubes  are  always  found  curled  downwards 
and  backwards,  adherent  to  the  posterior  surface  of  the 
uterus,  the  floor  of  the  pelvis,  the  posterior  surface  of 
the  broad  ligament,  and  not  seldom  to  the  anterior  surface 


480 


GYNECOLOGICAL  SURGERY 


of  the  rectum ;  whilst  on  many  occasions  the  operator 
will  find  that  both  tubes  have  in  addition  become  adherent 
to  each  other,  thus  entirely  filling  Douglas's  pouch  and 
surrounding  the  uterus  behind. 

On  account  of  the  important  structures  which  may  be 
adherent  to  the  diseased  appendages,  the  separation  must 
be   most   cautiously  proceeded   with,  and  every  care   also 


Fig.  334. — Elevating  the  appendage. 


should  be  taken  to  prevent  rupture  of  the  tube  and  the 
escape  of  pus. 

It  is  best  and  easiest,  therefore,  to  commence  the 
process  of  separation  by  passing  the  fingers  of  the  left  hand 
down  to  the  floor  of  the  pelvis,  and  then  to  insinuate  their 
tips,  with  the  palmar  surfaces  forwards,  under  the  lowest 
part  of  the  swelling,  below  the  spot  where  the  ovarian 
ligament  joins  the  uterus.  By  carefully  flexing  and  unflex- 
ing  the  fingers,  the  adhesions  are  gradually  separated  from 
below  upwards ;  and  it  may  be  necessary,  although  it  is 
best  avoided  if  possible,  to  help  this  separation  by  clamping 


SALPINGO-OOPHOREGTOMY 


481 


some  portion  of  the  appendage  with  ring  forceps  and 
pulling  it  up  with  the  right  hand  during  the  manipulations 
of  the  left  hand  (Fig.  334). 

The  facility  with  which  the  separation  is  performed 
depends  largely  on  an  appreciation  of  the  anatomical 
deformity  which  the  parts  have  undergone  in  consequence 
of  the  disease,  and  on  the  educated  sense  of  tissue-appre- 
ciation which  guides  the  manipulating  fingers  in  the  right 
plane  of  cleavage. 


Fig.  335. — Clamping  and  dividing  the  ovarico-pelvic 
ligament. 

The  appendages  having  eventually  been  delivered  through 
the  abdominal  opening,  each  is  removed  as  follows  : — ■ 

v.  Clamping  the  ovarian  vessels.  — -  With  a  pair  of 
pressure-forceps  the  ovarico-pelvic  ligament  is  clamped  near 
the  pelvic  brim  and  the  ovarian  artery  and  vein  are  thus 
temporarily  secured  (Fig.  335).  The  ligament  is  now  severed 
with  scissors,  distally  to  the  clamp,  and  the  outer  attach- 
ment of  the  appendage  is  thus  freed.  This  incision  should 
extend  more  than  an  inch  along  the  edge  of  the  broad 
ligament.  The  remaining  attachment  of  the  appendage, 
consisting  of  the  tube,  the  ovarico-uterine  ligament,  and  the 
2  F 


482 


GYNECOLOGICAL  SURGERY 


undivided  portion  of  the  broad  ligament,  is  now  transfixed 
by  a  needle  armed  with  silk  (Fig.  336)  and  tied  in  two 
halves,  the  loop  of  the  outer  section  of  the  ligature  fall- 
ing into  the  angle  at  the  end  of  the  incision  through  the 
ovarico-pelvic  ligament  (Fig.  337).     Care  should  be  taken, 


Fig.  336. — Transfixing  the  undivided  portion  of  the  pedicle. 

in  transfixing  this  portion  of  the  pedicle,  not  to  perforate 
the  uterine  end  of  the  ovarian  vessels  contained  within  it. 

vi.  Removal  of  the  appendage.- — The  appendage  is 
separated,  distally  to  the  transfixion  ligature,  with  scissors 
(Fig.  338). 

vii.  Ligature  of  the  ovarian  vessels. — The  proximal 
ends  of  the  ovarian  vessels  are  permanently  secured  by 
passing  a  No.  4  silk  ligature  under  each  ovarico-pelvic 
ligament  above  the  clamp  by  which  it  is  temporarily  held 
(Figs.  339  and  340). 

viii.  Closure  of  the  broad  ligaments. — The  raw  surface 


SALPINGO-OOPHOREGTOMY 


483 


Fig.  337. — Ligaturing  the  undivided 
portion  of  the  pedicle. 


Fig.  338. — Removing  the  appendage. 


4§4 


GYNECOLOGICAL  SURGERY 


left  at  the  top  of  each  broad  ligament  is  usually  obliterated 
sufficiently  by  the   ligatures   described.     If,   however,   the 


Fig.  339. — Passing  the  ligature  to  secure 
the  ovarico-pelvic  ligament. 


incision    through    the    ovarico-pelvic    ligament    has    been 
carried  too  far  inwards,   several  small  vessels   may  have 


Fig.  340. — Securing  the  ovarico-pelvic  ligament. 

been   opened  up   which   will   require   separate   control   by 
means  of  mattress-sutures. 


Plate  XIII.— Bilateral  Pyo-Salpinx. 


BISECTION   OF  UTERUS  485 

ix.  Closing  the  abdominal  cavity. — See  p.  285. 
Dressing  and  after-treatment. — See  p.   44  and  Chapter 

XXXII. 

Difficulties.  —  The  chief  difficulty  of  the  operation  is 
entirely  due  to  the  number  and  strength  of  the  adhesions, 
and  to  deal  with  these  the  skill  and  ingenuity  of  the  surgeon 
may  be  taxed  to  the  utmost.  If  the  adhesions  are  recent 
they  will  be  soft  and  may  be  separated  quite  easily,  but  if 
the  peritonitis  is  of  old  standing,  then  the  adhesions  will 
be  tough,  and  their  separation  may  even  be  impossible. 

In  advanced  cases  scissors  may  be  necessary  to  divide 
adhesions,  more  especially  those  in  the  neighbourhood  of 
the  ovarico-uterine  ligament,  which,  on  account  of  inflam- 
matory thickening  and  contraction,  may  anchor  the  diseased 
structures  to  the  side  of  the  uterus,  and  may  have  to  be 
separately  divided  to  set  the  mass  free. 

II.    BISECTION   OF  THE  UTERUS 

In  very  difficult  cases  of  double  pyo-salpinx,  when  the 
dilated  Fallopian  tubes  are  adherent  to  one  another  and 
to  the  floor  of  the  pelvis,  the  apparent  impossibility  of 
separating  the  diseased  structures  can  be  surmounted  by 
dividing  the  uterus  down  the  middle  and  removing  each 
half  with  its  corresponding  appendages,  a  method  devised 
by  Faure  and  described  in  the  following  paragraphs. 

Operation. — The  round  ligaments  having  been  ligatured 
and  divided  about  an  inch  from  the  uterus,  the  incisions 
dividing  them  are  joined  across  the  middle  line,  and  the  peri- 
toneum and  bladder  pushed  off  the  supravaginal  cervix. 
A  volsella  is  then  fixed  to  each  corner  of  the  uterus, 
which  is  divided  by  an  incision  down  the  middle  line  as 
far  as  the  internal  os  (Fig.  341). 

One  half  of  the  uterus  is  now  divided  transversely  with 
a  pair  of  scissors,  the  uterine  artery  being  clamped  as  it 
comes  into  view  (Fig.  342).  The  half  of  the  uterus  being 
thus  freed,  the  fingers  of  the  left  hand  can  lift  it  up  some- 
what and  so  get  under  the  pyo-salpinx,  which  it  will  be 


486 


GYNECOLOGICAL  SURGERY 


found  can  now  be  very  much  more  easily  separated  from 
the  structures  to  which  it  is  adherent. 

As  the  mass  composed  of  the  conjoined  uterus  and 
appendage  is  raised  out  of  the  pelvic  cavity,  the  ovarico- 
pelvic  ligament  is  put  on  the  stretch  and  clamped,  and 
the  pyo-salpinx  and  its  corresponding  half  of  the  uterus 
are  then  cut  away  (Fig.  343). 


Fig.  341. — Salpingo-oophorectomy  with 

hysterectomy    by  bisection  :    Bisecting 

the  uterus. 


The  diseased  appendage  and  the  half  of  the  uterus  on 
the  other  side  are  now  similarly  treated. 

The  uterine  and  ovarian  vessels  on  either  side,  already 
clamped,   are  now  ligatured  in  the  manner  described   at 

pp.  301-07  (Fig-  344)- 

The  hysterectomy  in  this  case  is  subtotal.  If  it  is 
desired  to  remove  the  whole  of  the  uterus,  the  bladder 
must  be  separated  entirely  from  the  supravaginal  cervix 
after   the    preliminary   incision   of   the    peritoneum    across 


BISECTION  OF   UTERUS 


Fig.  343. — Removing  the  left  half  of  the  uterus. 


488 


GYNAECOLOGICAL  SURGERY 


the  front  of  the  uterus  has  been  made.  The  splitting 
incision  is  then  carried  right  down  the  posterior  wall  until 
the  vagina  is  opened,  and,  the  fingers  of  the  left  hand 
having  been  inserted  therein,  the  anterior  wall  is  divided 
to  the  same  extent.  Each  half  of  the  cervix  is  cut  free 
from  its  lateral  attachment  to  the  vagina  and  gradually 
separated  from  the  broad  ligament  from  below  upwards, 
the  uterine  artery  being  seized  as  it  presents  or  spurts. 

Where  the  removal  of  the  uterus  is  carried  out  to  facili- 
tate the  extirpation  of  the  diseased  appendages  the  subtotal 


Fig.  344. — -Appearance  of  the  stumps  after 
removal  of  the  uterus  and  appendages. 


operation  will  suffice,  but  where  it  is  undertaken  because 
the  uterus  is  also  diseased  the  hysterectomy  should  be  total. 
In  such  circumstances  preliminary  splitting  of  the  uterus 
should  not  be  done  unless  it  facilitates  the  operation,  but 
the  technique  described  at  pp.  319-26  should  be  followed. 

Finally,  there  are  those  cases  in  which  after  the  removal 
of  the  appendages  the  uterus  is  left  so  lacerated  and  oozing 
as  to  forbid  its  being  conserved.  In  such  circumstances  the 
subtotal  operation  is  generally  the  best. 

Hysterectomy  in  cases  of  double  appendage  disease. 
— Many    authorities    maintain    that    in    cases    of    diseased 


BISECTION  OF  UTERUS  489 

appendages  the  uterus  should  always  be  removed  as  well, 
because  it  is  sure  to  be  diseased,  can  be  of  no  further 
use,  and  may  be  a  source  of  future  trouble.  There  can 
be  no  doubt  that  a  conserved  uterus  after  bilateral 
salpingo-oophorectomy  for  pyo-salpinx  may  be  a  source  of 
a  chronic  purulent  discharge,  especially  in  gonococcal  cases, 
whilst  in  some  instances  severe  haemorrhages  may  periodi- 
cally occur  from  it.  On  the  other  hand,  the  uterus  frequently 
is  apparently  healthy,  in  spite  of  the  presence  of  a  double 
pyo-salpinx,  especially  in  old-standing  cases  not  of  venereal 
origin.  Further,  the  removal  of  the  uterus,  especially  when 
total,  increases  the  severity  of  the  operation,  and  opens  up 
planes  of  healthy  connective  tissue  to  probable  infection. 

We  therefore  think  that  the  routine  performance  of 
hysterectomy  in  these  cases  is  to  be  deprecated.  If  any 
portion  of  the  ovary  can  be  conserved  it  is  well  to  leave 
the  uterus,  if  possible.  In  chronic  cases  of  double  pyo- 
salpinx  not  due  to  gonorrhoea,  we  should  also  content 
ourselves  with  removing  the  appendages  only.  In  acute 
septic  cases,  again,  in  which  the  patient  is  very  ill,  we 
believe  that  it  is  the  best  practice  to  let  the  uterus  alone, 
i.e.  to  do  as  little  as  is  necessary,  firstly  for  fear  of  opening 
up  healthy  pelvic  tissues  to  acute  infection,  and,  secondly, 
because  these  patients  stand  extensive  operative  procedures 
very  badly.  The  cases  most  suitable  for  entire  ablation 
of  the  uterus  and  adnexa  are  those  of  gonorrhoeal  pyo- 
salpinx  with  chronic  gonorrhoeal  metritis,  evidenced  by  a 
purulent  cervical  discharge  and  a  swollen,  soft, vascular  condi- 
tion of  the  uterus  as  viewed  through  the  abdominal  incision. 
Dangers  of  salpingo-oophorectomy. — In  separating  the 
adhesions — 

i.  The  intestines  may  be  wounded. 

ii.  Pus  may  escape. 

hi.  Large  vessels  may  be  opened. 

iv.  Bleeding  from  the  raw  surfaces  may  be    severe. 

v.  The  bladder  may  be  injured. 

vi.  The  broad  ligament  may  be  opened  up. 


4Q0  GYNECOLOGICAL  SURGERY 

i.  Wounding  intestine.  ■ — The  rectum  may  be  wounded, 
also  the  colon  or  the  small  intestine — most  commonly 
the  rectum.  The  wound  may  extend  through  the  peri- 
toneal coat  only,  or  through  the  muscular  coat,  or  the 
lumen  of  the  bowel  may  be  opened.  Generally  it  is  the 
peritoneal  covering  alone  that  is  injured,  when,  as  a  rule, 
no  harm  results,  although  a  path  is  thus  left  for  the  Bacillus 
coli  to  escape  and  perhaps  set  up  peritonitis.  Or  the  injured 
wall  may  slough  and  a  faecal  fistula  result.  Both  of  these 
complications  are  more  likely  if  the  muscular  coat  is  dam- 
aged. If  the  lumen  of  the  bowel  is  opened  and  escapes  de- 
tection, a  fatal  peritonitis  results,  or,  at  least,  a  faecal  fistula. 

The  treatment  depends  on  the  amount  of  injury.  If 
the  peritoneal  coat  is  simply  abraded,  it  had  better  be  let 
alone,  since  it  is  usually  impossible  satisfactorily  to  suture 
it.  Of  course,  all  bleeding  points  must  be  tied.  If  the 
muscular  coat  is  injured  or  the  bowel  opened,  the  wound 
must  be  repaired  according  to  the  directions  given  at 
p.  545.  In  any  case,  a  small  india-rubber  drainage-tube 
must  be  left  in  for  three  days  at  least. 

ii.  Escape  of  pus.  —  If  a  pyo-salpinx  or  tubo-ovarian 
abscess  is  ruptured  during  the  manipulations,  the  contents 
will  escape,  and  it  is  then  advisable  to  lower  the  patient 
into  a  more  horizontal  position  to  obviate  the  risk  of  any 
pus  escaping  past  the  swabs.  The  pus  should  be  carefully 
removed  with  swabs,  and  the  swabs  which  have  been 
previously  packed  round  the  diseased  area  in  case  of  this 
accident  occurring  should  not  be  removed  until  it  is  time 
to  close  the  abdominal  incision,  for  fear  of  soiling  the 
rest  of  the  abdominal  contents. 

The  old-fashioned  method  of  irrigating  the  pelvic  cavity 
in  these  cases  is  to  be  condemned.  It  does  no  good,  and 
may  do  harm  by  distributing  pus  over  the  abdominal 
cavity.  If  pus  escapes,  the  result  will  depend  upon  its 
nature.  In  recent  cases,  as,  for  instance,  an  acute  pyo- 
salpinx  following  abortion,  the  pus  is  very  infective,  and 
drainage  is  a  necessity. 


SALPINGO-OOPHORECTOMY  491 

In  a  very  large  majority  of  chronic  cases  the  pus  is 
sterile  ;  no  harm  results  from  its  escape,  and  many  operators 
do  not  consider  it  advisable  to  drain.  On  nearly  every 
occasion,  both  at  the  Middlesex  Hospital  and  at  the  Chelsea 
Hospital  for  Women,  in  which  the  pus  from  chronic  cases 
has  been  examined  bacteriologically,  organisms  have  been 
absent ;  and  this  experience  is  confirmed  by  that  of  most 
other  observers. 

We  think,  however,  that  it  is  best  that  at  the  end  of 
the  operation,  before  the  abdominal  incision  is  closed,  a 
small  drainage-tube  should  be  passed  down  into  the  pelvis 
and  left  in  situ  for  twenty-four  to  forty-eight  hours,  so 
that  if  suppuration  takes  place  a  path  may  be  available 
for  the  escape  of  the  pus. 

iii.  Injury  to  vessels. — It  occasionally  happens  that  the 
pyo-salpinx  is  adherent  to  the  brim  of  the  pelvis,  and  in 
separating  the  adhesions  great  caution  is  necessary  lest  the 
iliac  vein  be  injured.  This  accident  is  fortunately  rare. 
If  it  occurs,  a  swab  must  be  at  once  pressed  over  the  bleed- 
ing area  to  prevent  the  escape  of  blood,  and  then,  as  it  is 
raised,  the  operator  secures  the  opening  with  a  pair  of 
pressure-forceps,  after  which  the  vein  must  be  ligatured.  As 
ligature  of  the  iliac  vein  is  such  a  serious  matter,  a  lateral 
ligature  should  be  applied  if  possible.  In  cases  where  the 
broad  ligament  is  contracted  from  inflammation  so  that  it 
cannot  be  drawn  up,  the  iliac  vein  may  be  transfixed  by 
the  needle  while  securing  the  ovarian  vessels.  A  retro- 
peritoneal hsematoma  will  at  once  occur,  and  must  be 
dealt  with  (p.  42). 

iv.  Serious  oozing. —  After  the  removal  of  the  diseased 
structures,  raw  oozing  surfaces,  where  the  adhesions  have 
been  separated,  will  come  into  view.  The  positions  where 
these  are  most  marked  are  the  floor  of  the  pelvis,  the 
anterior  surface  of  the  rectum,  and  the  posterior  surfaces 
of  the  uterus  and  broad  ligament.  In  most  cases  the  oozing 
of  blood  soon  stops,  and  no  particular  treatment  is  neces- 
sary, but  in  some  the_  bleeding  is  free,  blood  welling  up 


492  GYNAECOLOGICAL  SURGERY 

into  the  pelvic  cavity  as  soon  as  the  swab  is  removed. 
A  careful  search,  aided  perhaps  by  a  hand-lamp,  must 
now  be  made  to  ascertain  if  there  is  any  particular  point 
where  the  bleeding  is  coming  from,  and  if  such  a  one  is 
discovered  it  should  be  secured  with  a  ligature  of  No.  2 
silk  tied  over  the  forceps  or  with  a  mattress-suture.  At 
times  the  bleeding  due  to  the  separation  of  the  adhesions  on 
the  posterior  surface  of  the  uterus  may  be  so  severe  that 
it  can  only  be  arrested  by  a  hysterectomy.  If  the  bleeding- 
point  happens  to  be  on  the  rectum,  care  will,  of  course,  be 
taken  not  to  include  more  of  the  bowel-wall  in  the  silk 
ligature  than  can  possibly  be  avoided.  If  the  condition  is 
one  of  general  oozing  rather  than  of  bleeding  from  definite 
points,  the  bleeding  may  often  be  stopped  by  the  applica- 
tion of  swabs  wrung  out  of  boiling  water.  If  this  is  not 
sufficient,  it  only  remains  to  pack  the  bleeding  area  with 
sterile  gauze,  which  is  removed  in  twenty-four  hours.  The 
oozing  may  be  stopped  by  swabbing  the  area  with  adrenalin, 
but  we  are  of  opinion  that  this  should  not  be  employed, 
since  it  affords  an  additional  channel  of  infection  and  its 
effect  on  diseased  vessels  is  very  slight  and  at  the  most 
temporary. 

v.  Injury  to  the  bladder.  — ■  In  some  cases  of  pyo- 
salpinx  the  inflammatory  mass  may  actually  raise  the 
whole  bladder  out  of  the  pelvis,  so  that  it  runs  some  risk 
of  being  wounded  on  the  peritoneal  cavity  being  opened. 

Where  a  large  mass  can  be  felt  jutting  up  above  the 
pubes,  this  is  particularly  to  be  borne  in  mind.  In  other 
cases  the  bladder  may  be  adherent  over  the  top  of  the 
uterus  to  the  omentum,  intestine,  or  the  diseased  tubes 
themselves,  and  may  be  torn  in  the  process  of  separation. 
In  either  event  the  wound  must  be  immediately  closed 
by  the  method  described  at  p.  539. 

vi.  Wounding  the  broad  ligament. — Occasionally  the 
diseased  appendages  are  so  adherent  to  the  back  of  the 
broad  ligament  that  in  separating  them  the  peritoneum  is 
torn  away  and  a  hole  is  left,  exposing  the  cellular  tissue, 


SALPINGO-OOPHOREGTOMY  493 

from  which  marked  bleeding  may  take  place.  This  hole 
must  be  closed  by  one  or  more  mattress-sutures  of 
silk. 

Besides  the  dangers  connected  with  separation  of  the 
adhesions,  there  is  the  risk  of — ■ 

Ligaturing  the  ureter. — -Just  where  the  ovarico-pelvic 
ligament  is  in  relation  with  the  brim  of  the  pelvis  the 
ureter  is  very  superficial,  and  can  be  felt  quite  easily 
by  rubbing  the  tissues  between  the  finger  and  thumb. 
Care  must  therefore  be  taken,  when  ligating  the  ovarian 
vessels  in  this  situation,  not  to  include  the  ureter. 

It  is  also  to  be  remembered,  when  closing  rents  in  the 
broad  ligament,  that  the  ureter  is  closely  adherent  to  the 
posterior  peritoneal  layer,  and  is  in  danger  of  being  trans- 
fixed by  the  needle  or  included  in  the  ligature. 

Alternative  methods  of  removing  diseased  appendages. 
— When  there  are  no  adhesions,  and  no  inflammatory 
contraction  of  the  broad  ligament,  and  the  Fallopian  tubes 
are  not  dilated  to  any  extent,  a  simple  method  of  removing 
the  appendages  consists  in  pulling  the  tube  up  with  the 
ovum  forceps,  transfixing  the  broad  ligament,  dividing 
the  ligature,  and  tying  it  on  both  sides,  as  described  at 
p.  456.  This  was  the  original  method  of  removing  the 
diseased  tube  in  all  cases,  but  it  has  two  grave  disadvan- 
tages in  cases  where  the  broad  ligament  is  at  all  thickened  : 
(1)  the  ligature  is  subjected  to  much  lateral  tension,  owing 
to  the  two  halves  of  the  pedicle  straining  in  opposite  direc- 
tions, with  the  danger  of  one  of  them  pulling  out  of  its 
grip  and  the  whole  ligature  becoming  useless  in  conse- 
quence ;  (2)  the  stump  left  is  bulky,  and  apt  subsequently 
to  contract  adhesions  and  become  a  chronic  source  of  pain. 
We  have,  therefore,  given  up  this  method  of  treating  the 
pedicle. 

If  total  removal  of  the  tube,  as  well  as  of  the  ovary, 
is  desired,  the  operation  described  must  be  so  modified 
as  to  include  the  excision  of  a  wedge-shaped  portion  of  the 
uterine  cornu  (see  Total  Salpingectomy,  p.  498). 


494  GYNECOLOGICAL  SURGERY 

III.   TUBO-OVARIAN   CYSTS   AND   ABSCESS 

These  two  conditions  often  give  rise  to  a  displacement 
very  similar  to  that  of  the  pseudo-broad-ligament  cyst 
(p.  470),  i.e.  the  enlarged  ovary  tends  to  under-burrow 
the  broad  ligament,  which  is  rotated  and  stretched  over 
its  upper  (cephalward)  and  anterior  surface.  The  edge  of 
the  stretched  broad  ligament  is,  of  course,  formed  by  the 
distended  Fallopian  tube.  In  many  cases  the  ovarian 
part  of  the  mass  is  easily  displaced  from  under  the 
broad  ligament,  but  not  infrequently,  especially  in  tubo- 
ovarian  abscess,  it  may  be  so  firmly  fixed  as  to  neces- 
sitate division  of  the  broad  ligament  before  it  can  be 
freed. 

The  technique  described  for  pseudo-broad-ligament  cysts 
is  then  to  be  followed,  except  that  the  division  of  this 
structure  and  the  tube  must  be  carried  out  right  up  at 
the  uterine  cornu,  that  is  across  the  non-dilated  isthmic 
portion  of  the  tube  just  as  it  leaves  the  uterus.  Special 
care  must  be  taken  securely  to  clamp  the  distal  end  of 
the  tube  at  its  point  of  division,  for  otherwise  the  whole 
contents  of  the  swelling  will  escape  therefrom.  For  the 
rest,  the  steps  are  similar  to  those  described  for  salpingo- 
oophorectomy  (pp.  476  and  493). 

IV.    OVARIAN   SUSPENSION 

Indications.- — Suspension  of  the  ovaries  is  indicated  in 
cases  of  ovarian  prolapse  causing  dyspareunia,  the  uterus 
being  in  its  normal  position.  It  is  also  indicated  where  the 
uterus  is  in  addition  retroverted  and  the  ovaries  remain 
in  the  pouch  of  Douglas  in  spite  of  rectification  of  the 
retroversion.  Lastly,  it  is  a  useful  method  to  pursue  where, 
after  salpingectomy  or  salpingostomy  for  salpingitis,  it 
is  desired  to  lift  the  ovaries  out  of  the  bed  of  the  adherent 
appendages. 

Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 


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Plate  XIV,— Right  Tubo-Ovarian  Cyst 


OVARIAN  SUSPENSION 

Operation,  i.  Opening  the  abdominal  cavity .- 


495 


—See  p.  276. 

ii.  Pleating  the  ovarico-uterine  ligament.— Whilst  an 
assistant  pulls  the  uterus  over  to  the  left  side,  the  operator 
holds  the  right  ovary  in  his  left  hand  and  puts  the  ovarico- 
uterine  ligament  on  the  stretch.  With  a  small  curved 
needle,  armed  with  No.  2  silk,  the  operator  next  trans- 
fixes the  ligament  at  its  insertion  into  the  uterus  and  ties 


Fig.  345. — Ovarian  suspension  :    First   step   in  the 
insertion  of  the  pleating  suture. 

a  knot  there  (Fig.  345),  after  which  he  passes  the  portion 
of  the  suture  attached  to  the  needle  backwards  and  forwards 
through  the  ovarico-uterine  ligament  till  the  inner  pole 
of  the  ovary  is  reached  (Fig.  346). 

The  needle  being  cut  away,  the  two  ends  of  the  suture 
are  tied  together,  with  the  result  that  the  ligament  is 
thrown  into  pleats  and  the  ovary  assumes  more  or  less 
its  normal  position  (Fig.  347). 

iii.  Closing  the  abdominal  cavity- — See  p.  285. 

Dressing  and  after-treatment. — See  p.  44  and  Chapter 

XXXII. 


496 


GYNAECOLOGICAL  SURGERY 


Fig.  346. — The  pleating  suture  applied. 


Fig.  347.— Shortening  the  ovarian  ligament. 


Plate  XV.— Large  Ovarian  Abscess  of  the  Left  Side. 


SALPINGECTOMY  497 

V.  RESECTION   OF   A   PORTION   OF   THE   OVARY 

When  operating  on  a  patient  for  disease  of  the  uterine 
appendages,  the  surgeon  often  discovers  that  only  a  small 
portion  of  the  ovary  is  implicated  and  that  the  greater 
portion  of  it  is  apparently  healthy.  In  these  circumstances 
we  think  that  the  treatment  should  be  as  conservative  as 
possible,   only   the   diseased  portion  being  resected. 

Operation.  — ■  There  are  three  methods  of  resecting 
portions   of   the    ovary  : 

i.  In  the  case  of  a  single  cyst  of  small  size  it  may  be 
simply  punctured,  or  a  portion  of  the  cyst-wall  is  excised. 

2.  The  diseased  portion  of  the  ovary  may  be  removed 
from  the  healthy  by  a  wedge-shaped  incision,  the  edges 
of  which  are  subsequently  approximated  with  fine  silk 
sutures. 

3.  A  transfixion-ligature  may  be  made  to  constrict  the 
ovary  above  the  diseased  portion,  which  is  then  removed. 
This  method  of  placing  the  ligature  is  often  employed 
while  removing  a  diseased  appendage  or  an  ovarian  cyst 
when  it  is  desired  to  conserve  a  portion  of  the  ovary. 

VI.  SALPINGECTOMY 

Salpingectomy  is  indicated  when  the  Fallopian  tube  is 
hopelessly  diseased  but  the  ovary  apparently  healthy.  It 
is  contra-indicated  in  cases  of  malignant  disease  of  the 
tube,  in  which  the  internal  genital  organs  of  the  patient 
should  be  removed,  whilst  in  certain  cases  of  hydro-salpinx 
and  haemato-salpinx  the  more  conservative  operation  of 
salpingostomy  is  preferable. 

Subtotal  Salpingectomy 

Preparation  of  the  patient. — See  pp.  82-86. 
Instruments. — See  p.  276. 

Operation,     i.  Opening  of  the  abdomen. — See  p.  276. 
ii.  Separation   and   amputation    of    the    Fallopian   tube. 
— The  ampullary  end  of  the  Fallopian  tube  is  now  caught  in 

2G 


498 


GYNAECOLOGICAL  SURGERY 


pressure-forceps  and  pulled  a  little  outwards  and  upwards 
so  as  to  put  it  on  the  stretch,  and  a  pair  of  pressure-forceps 
is  applied  to  the  ovarian  fimbria  and  outer  edge  of  the 
mesosalpinx  parallel  to  the  course  of  the  tube  and  about 
a  quarter  of  an  inch  from  it.  The  tube  is  now  dissected 
off  the  mesosalpinx  as  far  as  its  uterine  end,  then  a  pair  of 
pressure-forceps  is  applied  at  its  junction  with  the  uterus 
and  the  tube  is  cut  free  (Fig.  348). 


Fig.  348. — Subtotal  salpingectomy  :     Removing  the  tube. 

iii.  Ligaturing  the  mesosalpinx. — The  cut  edge  of  the 
mesosalpinx,  with  any  bleeding  vessels  therein,  is  secured 
by  several  mattress-sutures  of  No.  2  silk,  and  the  uterine 
stump  of  the  tube  is  finally  ligatured  with  the  same  material 
(Fig.  349). 

iv.  Closing  the  abdomen. — See  p.  285. 

Dressing  and  after-treatment. — See  p.  44  and   Chapter 

XXXII. 

Total  Salpingectomy 

This  operation  is  indicated  especially  in  acute  tubal 
infections    and    pyo-salpinx,    and    it    has    for    its    object 


SALPINGOSTOMY  499 

the    removal    of    the    entire    tube    as    far    as    the    uterine 
ostium. 

Operation. — -The  steps  of  the  operation  are  those  pre- 
viously described  under  partial  salpingectomy,  but,  instead 
of  clamping  and  amputating  the  tube  at  its  junction  with 
the  uterine  wall,  a  wedge-shaped  portion  of  this  latter, 
containing    the    interstitial    part    of    the  tube,  is    excised 


Fig.  349. — -Ligaturing  the  stump  of  the  tube. 

(Fig.  35°) .  and  the  wound  united  with  mattress-sutures  of 
No.  4  silk  (Fig.  351).  A  continuous  suture  is  then  applied, 
beginning  at  the  outer  point  of  the  cut  edge  of  the  meso- 
salpinx and  ending  at  the  uterine  end  of  the  incision  in  the 
cornu  (Fig.  352). 

VII.  SALPINGOSTOMY 

In  certain  cases  of  hydro-salpinx,  and  haemato-salpinx 
not  due  to  tubal  gestation,  in  which  the  tube-wall,  though 
thinned  by  distension,  is  otherwise  healthy,  the  operation 
of  salpingostomy  is  indicated  in  preference  to  salpingectomy. 


500 


GYNECOLOGICAL  SURGERY 


Fig.  350. — Total  salpingectomy  :    Excising  the  uterine  cornu. 


Fig.  351. — Passing  the  mattress-sutures. 


SALPINGOSTOMY 


501 


Fig.  352. — Applying  the  continuous  suture. 


Fig.  353.— Salpingostomy  :   Slitting  the  Fallopian  tube. 


502 


GYNAECOLOGICAL  SURGERY 


Preparation  of  the  patient. — See  pp.  82-86. 

Instruments. — See  p.  276. 

Operation,     i.  Opening  the  abdomen. — See  p.  276. 

ii.  Delivery  of  the  Fallopian  tube. — See  p.  479. 

iii.  Slitting  the  Fallopian  tube. — The    tube    is     slit    up 

for  about  an  inch 
along  its  free 
border,  care  being 
taken  not  to  ex- 
tend the  incision 
to  the  junction 
of  the  ampulla 
with  the  isthmus 
(Fig.  353)- 

iv.  Formation 
of  the  new  os- 
tium.— The  con- 
tents of  the  tube 
having  been 
evacuated,  the 
mucous  m  e  m- 
brane  on  each 
side  of  the  inci- 
sion is  everted 
and  stitched  to 
the  peritoneum 
covering  the  tube 
on  its  lateral  as- 
pect with  inter- 
rupted No.  1  silk 
sutures  (Fig.  354). 

v.  Closing  the  abdominal  wound. — See  p.  285. 

Dangers. — The  bleeding  from  the  divided  tube-wall 
is  at  times  quite  free.  If  it  is  not  arrested  by  the  inter- 
rupted sutures,  a  hematoma  may  form  which  will  invali- 
date the  operation. 

Dressing  and  after-treatment — See  p.  44  and  Chap.  xxxn. 


Fig.  354. — Forming  the  new  ostium. 


CHAPTER    XXVI 

OPERATIONS  FOR  EXTRA-UTERINE  GESTATION 

The  operative  treatment  of  extra-uterine  gestation  depends 
upon  the  period  of  pregnancy. 

FIRST    THREE    MONTHS 

The  operations  that  may  be  indicated  in  the  first  three 
months  are  salpingectomy,  oophorectomy,  salpingo-oopho- 
rectomy,  hystero-salpingectomy,  salpingectomy  with  partial 
hysterectomy. 

In  our  opinion,  every  case  of  extra-uterine  gestation 
diagnosed  in  the  first  three  months  should  be  operated 
upon.  The  non-observance  of  this  rule  is  based  upon  the 
assumption  that  the  ovum  is  dead  and  that  the  blood  al- 
ready effused  will  be  absorbed  without  further  trouble.  Both 
these  assumptions  are  frequently  found  to  be  wrong.  It 
is  impossible  to  diagnose  with  certainty  the  death  of 
the  extra-uterine  foetus,  and  even  if  the  foetus  be  dead 
the  trophoblast  in  the  wall  of  the  gestation-sac  may  continue 
to  grow,  and,  invading  the  tube-wall,  lead  to  a  further 
haemorrhage. 

The  second  contention,  that  the  blood  will  be  absorbed 
without  further  trouble,  is  equally  untenable,  because, 
quite  apart  from  the  fact  that  in  many  of  the  cases  the 
patients  are  ill  in  bed  for  weeks  and  perhaps  there  is  sup- 
puration in  the  end,  there  remains  the  danger,  which  is 
very  real,  that  in  the  process  of  absorption  of  the  blood- 
clot,  adhesions  may  form  which  may  permanently  occlude 
the  healthy  tube,  may  fix  and  retrovert  the  uterus,  or  may 
cause  intestinal  obstruction.  We  would  draw  particular 
attention  to  the  frequency  with  which  the  opposite  tube  is 

503 


504  GYNECOLOGICAL  SURGERY 

found  occluded  and  distended  in  operations  for  hematocele, 
whereas  in  those  for  acute  tubal  rupture  it  is  almost  in- 
variably found  to  be  healthy.  To  our  minds,  one  of  the 
strongest  reasons  for  immediate  operation  on  an  early 
tubal  gestation  is  the  preservation  of  the  unaffected  tube. 

Lastly,  it  has  been  shown  by  Hamilton  Bell  and  others 
that  the  mortality,  to  say  nothing  of  the  morbidity,  of 
cases  left  to  take  their  own  course  is  higher  than  of  those 
treated  by  operation. 

It  is  always  desirable  to  save  the  ovary  if  possible,  and 
this  can  usually  be  done  in  the  cases  of  acute  tubal  rupture, 
and  especially  when  pregnancy  is  very  early.  Where, 
however,  a  haematocele  has  formed,  or  the  distension  of  the 
tube  is  very  great,  the  ovary  may  be  so  adherent  or  dis- 
integrated that  its  removal  with  the  tube  becomes  necessary. 
In  ovarian  pregnancy  the  same  holds  good,  but  the  ovary 
alone  may  be  removed  in  early  cases  of  acute  rupture. 
The  operative  technique  in  any  of  these  cases  is  similar 
to  that  already  described  under  Salpingectomy  (p.  497), 
Salpingo-oophorectomy  (p.  476),  and  Oophorectomy  (ovari- 
otomy) (p.  453),  but  we  draw  attention  to  a  few  additional 
points. 

Acute  rupture  of  the  gestation-sac  with  hsemo-peri- 
toneum. — There  is  no  class  of  case  in  which  the  symptoms 
supervene  with  more  dramatic  suddenness  and  intensity 
than  in  acute  tubal  rupture,  nor  any  in  which  prompt 
and  determined  surgical  measures  are  rewarded  with  more 
pleasurable  success. 

The  primary  object  of  controlling  the  bleeding  tube 
should  be  carried  out  as  quickly  as  possible.  This  effected, 
the  surgeon  may  proceed  with  the  rest  of  the  opera- 
tion with  such  deliberation  as  the  state  of  the  patient 
admits. 

Directly  the  abdominal  muscles  are  separated,  the 
peritoneum  will  be  seen  to  have  a  bluish  tinge,  due  to  the 
blood  beneath  it.  The  abdomen  being  opened,  no  time 
should  be   wasted  in  clearing  out  the  effused  blood,   but 


Plate  XVI  — Ruptured  Tubal   Pregnancy. 


EXTRA-UTERINE   GESTATION  505 

the  hand  should  be  passed  down  to  the  uterus,  and  with 
this  as  a  guide  the  ruptured  tube  is  discovered,  grasped, 
pulled  out  of  the  wound,  and  clamped.  The  appendage  is 
now  examined,  and  the  whole  of  it,  if  diseased,  or  the  tube 
or  the  ovary  only  if  conservation  be  possible,  is  removed. 
The  opposite  tube  having  been  examined  and  found  healthy, 
the  effused  blood  in  the  pelvis  is  rapidly  cleared  out,  and 
swabs  on  forceps  are  passed  up  into  the  loin  pouches  to 
remove  any  accumulation  there.  Where,  however,  the 
patient's  condition  is  very  bad,  it  is  a  mistake  to  waste 
time  in  trying  to  remove  all  the  blood,  as  this  involves  a 
great  deal  of  handling  of  the  intestines.  In  such  cases, 
while  the  surgeon  is  securing  the  bleeding-point,  an  assistant 
exposes  the  median  cephalic  or  basilic  vein,  and  directly 
the  haemorrhage  is  under  control  he  begins  saline  venous 
infusion. 

Rupture  of  the  gestation-sac  with  hematocele.  —  In 
these  cases  the  omentum  will  be  found  adherent  to  the 
fundus  of  the  uterus  and  the  appendage  on  the  diseased  side. 
The  omentum,  which  is  often  discoloured,  is  separated 
(Fig.  355),  and  the  collection  of  black  blood-clot  forming 
the  hsematocele  is  exposed  and  scooped  out  with  the  left 
hand  (Fig.  356).  It  will  be  found  that  the  haemato-salpinx 
is  buried  in  this  blood-clot  at  the  bottom  of  the  pelvis, 
from  which  it  is  displaced  in  the  manner  described  at  p.  479. 
The  appendage,  being  raised,  is  dealt  with  by  complete 
removal  (p.  476)  or  by  salpingectomy  (p.  497). 

The  opposite  tube  is  next  examined.  It  will  frequently 
be  found  to  be  in  a  condition  of  hydro-salpinx  or  hemato- 
salpinx. If  so,  it  should  be  opened,  emptied,  and 
salpingostomy  carried  out  (p.  494). 

Not  seldom  from  the  bed  of  the  separated  tube  there 
will  be  troublesome  oozing,  which  can  generally  be  arrested 
with  hot  sponges. 

The  question  of  drainage  depends  mostly  on  the  previous 
temperature  of  the  patient.  If  it  has  been  considerable, 
and  irregular  in  type,  suggesting  septic  infection,  a  drainage- 


5o6 


GYNECOLOGICAL  SURGERY 


Fig.  355. — Operation  for  hematocele 
Separating  adherent  omentum. 

tube  should  certainly  be  inserted  ;    in  other  cases  this  is 
not  necessary. 

Rupture  of   the  gestation-sac    with  a   broad-ligament 


Fig.  356. — Removing  the  blood-clot. 


EXTRA-UTERINE  GESTATION  507 

hsematoma.  —  The  treatment  of  this  class  of  case  is  con- 
ducted on  lines  similar  to  those  described  for  rupture  with 
hematocele,  the  only  difference  being  in  the  treatment  of 
the  sac  left  after  the  evacuation  of  the  haematoma.  When 
the  effused  blood  is  limited  to  the  mesosalpinx,  it  is  generally 


Fig.  357. — Enucleating  the  haemato-salpinx. 

possible  to  remove  it  en  masse  with  the  tube  ;  if,  however, 
it  has  extended  into  the  broad  ligament  proper  and,  as  in 
bad  cases,  has  also  lifted  the  peritoneum  off  the  lateral 
pelvic  wall  and  iliac  fossa  and  on  the  left  side  made  its 
way  into  the  mesentery  of  the  colon,  it  is  best,  having 
removed  the  tube  and  evacuated  the  blood  from  the  sac 
in  the  broad  ligament,  to  stitch  the  opening  in  the  sac  to 


5o8  GYNECOLOGICAL   SURGLRY 

the  parietal  wound,  pack  it  lightly  with  gauze,  and  allow 
it  to  granulate  up.  In  very  bad  cases,  especially  where 
there  is  difficulty  in  controlling  the  bleeding  from  the  wall 
of  the  sac,  the  uterus  and  upper  part  of  the  broad  ligament 
may  be  removed,  and  the  anterior  peritoneal  flap  thus  ob- 
tained used  to  cover  over  the  raw  surface  or  base  of  the  sac. 
Ruptured  interstitial  gestation. — Hysterectomy,  or  par- 
tial hystero-salpingectomy,  is  indicated  in  the  rare  con- 
dition of  ruptured  interstitial  gestation.  In  most  of  the 
recorded  cases  the  former  operation  has  been  performed. 
An  alternative  proceeding  is  to  remove  the  wedge-shaped 
portion  of  the  uterine  tissue  containing  the  gestation-sac 
alone.  We  have  performed  this  operation  with  success. 
Its  merit  lies  in  the  conservation  of  the  uterus  ;  but  in 
respect  of  time  and  rapidity  of  hsemostasis  this  procedure 
is  inferior  to  the  former  operation. 

FOURTH  AND   FIFTH  MONTHS 

As  after  the  third  month  the  gestation  can  no  longer 
be  confined  to  the  tube,  but  is  either  intraperitoneal  or 
intraligamentous,  and  as  with  the  advance  of  pregnancy 
the  placental  surface  becomes  increasingly  large  and  the 
vascularity  of  the  parts  increasingly  greater,  these  cases 
present  features  peculiar  to  themselves.  It  is  a  fact  that, 
having  passed  the  limit  of  the  third  month  safely,  the 
gestation  sometimes  proceeds  to  term  without  further 
trouble,  but  at  other  times  the  surgeon  will  be  called  upon 
to  interfere  because  some  acute  symptoms  have  arisen.  In 
these  cases  the  whole  crux  of  the  situation  is  the  treatment 
of  the  placenta.  If  the  child  is  dead,  the  placenta,  can  in 
most  cases  be  removed  without  serious  risk.  If  the  child  is 
alive,  the  position  of  the  placenta  requires  consideration. 
If  the  sac  is  intraperitoneal,  the  placenta  is  most  commonly 
adherent  to  the  back  and  fundus  of  the  uterus,  the  affected 
tube,  the  back  of  the  broad  ligament,  and  the  omentum — 
positions  in  which  it  is  possible  to  control  the  vessels  before 
attempting   its   removal.      In   other  cases,   however,    it   is 


EXTRAUTERINE  GESTATION  509 

adherent  to  the  intestine  or  the  iliac  fossa,  in  which  event 
it  is  not  possible  to  follow  this  procedure.  If  the  sac  is 
intraligamentous  the  case  is  more  serious  still,  for  in  this 
situation  nearly  the  whole  of  the  chorion  is  placental,  and 
it  may  be  impossible  to  remove  the  child  without  incising 
it,  while  the  vessels   cannot  be   controlled  beforehand. 

On  opening  the  abdomen,  therefore,  the  surgeon  should 
very  carefully  study  the  problem  that  lies  before  him,  and 
avoid  the  premature  separation  of  any  adhesions  before 
he  has  settled  upon  his  plan  of  action. 

If  the  gestation-sac  is  intraperitoneal,  and  the  pregnancy 
has  not  advanced  more  than  five  months,  we  think  that  it 
is  better  in  all  cases  to  attempt  its  complete  extirpation. 
Before  starting  upon  this,  as  many  tributary  vessels  as 
possible  in  the  omentum,  the  ovarico-pelvic  ligament,  and, 
if  necessary,  on  the  opposite  side  of  the  uterus,  should  be 
ligatured.  This  done,  the  gestation-sac  must  be  opened, 
the  foetus  removed,  and  the  placenta  rapidly  peeled  off. 
If  the  sac  is  intraligamentous,  the  course  to  be  pursued 
is  more  difficult  of  decision.  Where  the  gestation  has  not 
advanced  beyond  the  fourth  month,  or  in  any  case  where 
the  sac  is  so  situated  that  its  entire  removal  appears 
feasible,  we  believe  it  is  best  to  do  this.  The  haemorrhage, 
which  is  bound  to  be  free,  may  be  minimized  by  removing 
the  uterus  as  well,  beginning  the  operation  on  the  side 
opposite  to  the  gestation-sac  and  securing  the  uterine 
artery  on  the  same  side  as  the  supravaginal  cervix  is  cut 
across,  and  before  the  extirpation  of  the  sac. 

Where,  however,  the  gestation  has  advanced  to  the 
fifth  month,  or  the  sac  is  deeply  embedded  between  the 
layers  of  the  broad  ligament,  the  safest  course  is  to  open 
the  sac  and  membranes,  remove  the  child,  and  then  deli- 
berately sequester  the  placenta  by  closing  the  aperture  in 
the  peritoneum  of  the  broad  ligament  with  sutures.  The 
closed  sac  should  then  be  fixed  to  the  parietal  incision,  so 
that  in  case  it  has  subsequently  to  be  reopened  for  sepsis 
or  haemorrhage  the  operation  may  be  extraperitoneal. 


5io  GYNECOLOGICAL  SURGERY 

The  rationale  of  sequestration  of  the  placenta  is  founded 
on  the  good  results  obtained  by  nature  in  cases  of  spon- 
taneously sequestered  extra-uterine  gestation.  It  goes 
without  saying  that  the  operation  must  be  conducted  with 
the  greatest  asepsis. 

Sometimes  it  is  impossible  to  incise  the  intraligamentous 
sac  without  cutting  through  the  placenta.  In  such  an 
event  sequestration  may  still  be  proceeded  with  if  the 
bleeding  from  the  cut  edges  of  the  placenta  can  be  arrested 
by  sutures.  Where  it  cannot,  or  where  part  of  the  placenta 
is  definitely  separated,  it  will  be  necessary  at  all  costs  to 
extirpate  it  in  the  manner  described  above. 

Instead  of  sequestering  the  placenta,  the  old  plan  of 
stitching  the  sac  to  the  abdominal  wound  (marsupialization) 
and  draining  it  may  be  adopted ;  but  this  is  a  very  fatal 
proceeding,  as  the  placenta  nearly  always  sloughs,  and  the 
patient  dies  either  of  secondary  haemorrhage  as  it  separates 
or  of  acute  sepsis. 

SIXTH,   SEVENTH,  EIGHTH  AND    NINTH    MONTHS 

Where  extra-uterine  gestation  has  advanced  to  or 
beyond  the  sixth  month  without  causing  urgent  symptoms, 
it  has  been  conclusively  shown  that  the  safest  course  to 
pursue  is  to  let  the  patient  alone,  in  the  good  hope  that 
the  death  of  the  child  will  sooner  or  later  occur,  after  which 
it  can  be  removed  with  the  placenta  in  comparative  safety. 

When  urgent  symptoms  arise,  the  surgeon  must  interfere, 
and  the  difficulties  that  face  him  are  those  detailed  in  the 
preceding  section,  magnified  in  proportion  to  the  further 
advance  of  the  pregnancy.  If  the  placenta  is  below  the 
child,  the  best  course  is  to  remove  the  latter  and  then 
close  the  sac  and  sequester  the  placenta.  Where  the 
placenta  is  already  much  separated,  the  haemorrhage  may 
compel  its  removal,  in  which  event  the  surgeon  must 
control  the  bleeding  by  forceps  and  ligatures  applied  as 
rapidly  as  possible,  or,  if  these  do  not  suffice,  the  sac  must 
be  tightly  plugged  with  gauze.     Marsupialization  of  the  sac 


EXTRA-UTERINE  GESTATION  511 

and  drainage  are  to  be  avoided,  if  possible,  on  account  of 
the  risks  already  mentioned.  If  the  placenta  is  above 
the  child  and  delivery  cannot  be  effected  without  cutting 
through  it,  the  bleeding  resulting  may  necessitate  its 
removal,  but  an  attempt  should  first  be  made  to  arrest 
the  haemorrhage  by  ligatures.  In  some  cases,  however,  the 
child  can  be  delivered  without  interfering  with  the  placenta, 
and  after  the  child's  removal  it  is  found  that  its  extirpation 
is  possible,  as,  for  instance,  if  its  main  blood-supply  is 
derived  from  the  omental  vessels.  In  such  circumstances 
it  should  be  extirpated  or  else  treated  by  sequestration 
of  the  sac.  Lastly,  in  some  intraligamentous  cases,  where  a 
quick  placenta  lies  above  the  child  and  has  to  be  incised  in 
order  to  get  it  out,  the  best  that  can  be  done  is  to  control  the 
bleeding  in  the  cut  edges  with  mattress-sutures,  close  the  sac, 
and  fix  it  to  the  abdominal  wound,  which  is  sutured  over  it. 
The  whole  question  of  the  operative  treatment  of 
advanced  extra-uterine  gestation  is  beset  with  great  diffi- 
culties, the  more  so  since  these  cases  are  so  rare  that  no 
individual  surgeon  has  had  sufficient  experience  to  en- 
able him  to  generalize,  while  the  conditions  found  are  so 
different  in  their  anatomy  that  no  two  cases  are  alike. 
Treatment  must  be  founded  on  a  careful  consideration  of 
the  anatomical  peculiarities  of  each  case,  with  due  regard 
to  the  general  rules  given  above. 

EXTRA-UTERINE   GESTATION   AFTER   TERM    .\ 

These  cases  present,  as  a  rule,  no  special  difficulties. 
The  child  and  placenta,  being  dead,  can  be  removed  with 
comparative  safety.  The  operation  should  be  postponed 
for  three  months  except  when  the  signs  of  fever  and  pain 
show  that  the  fcetal  sac  has  become  infected.  Where 
suppuration  has  occurred  in  the  sac,  the  case  must,  of 
course,  be  at  once  operated  upon.  No  general  rules  can  be 
laid  down.  Some  of  these  cases  are  easily  dealt  with,  but 
in  others,  where  fistulous  tracks  have  formed  into  the  intes- 
tine and  bladder,  the  operation  may  be  very  formidable. 


CHAPTER    XXVII 

OVARIAN    TUMOURS    COMPLICATING    PREG- 
NANCY, LABOUR,  AND  THE  PUERPERIUM 

The  well-recognized  rule  that  if  a  woman  has  an  ovarian 
tumour  the  sooner  it  is  removed  the  better  it  will  be  for 
her,  holds  good  with  but  few  exceptions,  be  she  pregnant, 
in  labour,  or  lying-in.  An  ovarian  tumour  is  more  liable 
to  rupture,  inflame,  undergo  axial  rotation,  or  bleed  when 
any  of  the  above-named  conditions  are  present  than  in 
their  absence. 

OVARIAN  TUMOUR  AND  PREGNANCY 

The  tumour,  on  account  of  the  greater  blood-supply, 
will  grow  more  rapidly,  and  on  this  account  the  resulting 
pressure  may  cause  troublesome  vomiting  or  serious 
oedema.  Again,  the  patient  is  more  likely  to  miscarry  on 
account  of  the  presence  of  the  tumour,  and  the  tumour 
itself  is  particularly  liable  to  undergo  axial  rotation.  When, 
in  addition,  it  is  remembered  that  she  has  to  go  through 
the  perils  of  labour,  it  is  evident  that  the  tumour  should 
be  removed  with  the  least  possible  delay.  As  a  rule,  the 
results  of  removal  are  particularly  gratifying,  the  pregnancy 
in  the  majority  of  cases  continuing  to  term  without  further 
trouble.  It  must  be  remembered,  however,  that  the  risk 
of  miscarriage  after  the  enucleation  of  a  broad-ligament 
cyst  is  greater  than  after  a  simple  ovariotomy. 

Great  care  must  be  exercised,  when  operating  upon 
ovarian  tumour  complicating  pregnancy,  not  to  injure  the 
uterus.  If  the  uterus  is  injured  it  may  be  necessary  to 
open  it  and  remove  the  ovum  after  the  manner  of  a  Csesarean 
section,  or  if  the  wound  is  slight  its  suture  may  suffice. 

512 


OVARIAN  TUMOURS  AND  LABOUR      513 

There  are  three  exceptions  to  the  rule  that  the  tumour 
should  be  removed :  one,  when  a  small  cyst  well  out  of  the 
pelvis  is  discovered  at  the  end  of  pregnancy,  in  which 
event  it  may  be  allowed  to  remain  till  the  puerperium  is 
well  established  ;  a  second,  when  the  patient  is  very  ill, 
perhaps  with  oedema  of  the  lungs  from  the  over-distension, 
in  which  case  the  pressure  may  be  temporarily  relieved  by 
tapping  the  cyst,  and  its  removal  undertaken  later  ;  and 
a  third,  when  the  tumour  has  been  inflamed  and  the  adhe- 
sions are  so  numerous  that  separation  of  them  would  cause 
death  from  haemorrhage.  This  condition  cannot  be  well 
diagnosed  until  the  abdominal  cavity  is  opened  ;  and  the  ex- 
perienced operator  will  rest  satisfied  with  simple  drainage  or 
with  closing  the  abdomen  and  subsequently  tapping  the  cyst. 

Whilst,  as  has  been  said,  the  performance  of  ovariotomy 
on  a  pregnant  woman  does  not  as  a  rule  induce  miscarriage 
or  premature  labour,  yet  a  liability  to  do  so  is  present  more 
or  less  in  all  cases.  For  this  reason  it  is  our  practice,  in 
such  cases,  to  administer  morphia  (I  gr.)  hypodermically 
before  recovery  from  the  anaesthetic,  and  to  keep  the 
patient  under  the  influence  of  the  drug  for  forty-eight  hours 
by  repeated  small  doses.  Further,  the  surgeon  has  to 
remember  the  tension  that  will  be  thrown  upon  the  scar 
if  the  pregnancy  proceeds,  and  the  strain  upon  the  stitches 
uniting  the  wound  if  labour  comes  on  before  it  has  united 
strongly.  For  these  reasons  special  care  must  be  taken  to 
suture  the  wound  as  strongly  as  possible,  and  the  ordinary 
three-tier  method  should  be  supplemented  by  through-and- 
through  sutures. 

OVARIAN  TUMOUR  AND   LABOUR 

The  accidents  that  are  liable  to  occur  when  an  ovarian 
tumour  complicates  labour  depend  upon  the  position  of 
the  tumour,  as  also  in  some  respects  does  the  treatment. 

If  the   tumour   is   above   the   presenting  part,   it  may 
rupture,   its   pedicle   may  become   twisted,    or  it   may  be 
injured  so  that  later  it  inflames. 
2  H 


514  GYNECOLOGICAL  SURGERY 

If  the  tumour  is  below  the  presenting  part,  it  will 
obstruct  labour,  leading  to  rupture  of  the  uterus,  of 
the  vagina,  or  of  the  rectum.  On  occasions  the  tumour 
itself  ruptures,  or  is  so  bruised  that  it  subsequently  in- 
flames. 

Lastly,  after  the  passage  of  the  child  its  sudden  elevation 
may  result  in  torsion  of  its  pedicle. 

Treatment. — -When  the  tumour  is  above  the  presenting 
part  it  is  rare  for  obstruction  to  occur,  and  labour  may 
be  allowed  to  terminate,  the  growth  being  removed  as 
soon  as  the  patient  is  convalescent  or  directly  any  untoward 
symptoms  arise. 

When  the  tumour  is  below  the  presenting  part  obstruc- 
tion will  result.  This  is  usually  absolute,  but  occasionally 
the  uterine  contractions  may  eventually  rupture  the  cyst 
and  allow  the  child  to  escape.  Very  rarely  it  has  happened 
that  the  tumour  has  been  forced  down  by  the  advancing 
child  and  expelled  through  a  ruptured  rectum  or  vagina 
via  the  anus  or  the  vulva. 

As  a  permanent  obstruction  would  lead  to  the  rupture 
of  the  uterus,  and  as  the  alternatives  of  the  cyst  being 
ruptured  or  expelled  are  highly  dangerous,  if  the  obstruc- 
tion cannot  be  relieved  by  pushing  up  the  tumour  past 
the  presenting  part,  under  an  anaesthetic,  and  delivering 
the  child  with  forceps,  all  are  agreed  that,  with  one  excep- 
tion, the  proper  treatment  is  to  remove  it  either  through 
the  abdomen  or  through  the  vagina,  the  better  route  being 
the  abdominal  one.  After  removal  of  the  tumour,  the 
child  should  be  delivered  with  forceps  to  prevent  the  labour- 
pains  from  straining  the  sutures. 

The  remarks  on  page  513  concerning  the  necessity  for 
firm  closure  of  the  abdominal  wound  should  be  read  in  this 
connexion. 

The  exception  referred  to  is  when  the  attendant  is  not 
skilled  in  abdominal  surgery  and  cannot  obtain  the  services 
of  one  who  is.  In  that  case,  the  tumour  will  have  to  be 
tapped  per  vaginam,  and   the  child  delivered  with  forceps 


OVARIAN  TUMOURS  AND  LABOUR      515 

or  by  craniotomy.  This  entails  the  risk  of  peritonitis  from 
escape  of  some  of  the  cyst-fluid  into  the  pelvic  cavity, 
while  the  cyst-wall  may  subsequently  slough  from  bruising 
during  delivery.  It  is  therefore  advisable,  if  the  attendant 
has  been  forced  to  tap  the  cyst,  that  the  tumour  should 
be  removed  as  soon  as  possible  after  the  termination  of 
labour. 

OVARIAN  TUMOUR  AND  THE  PUERPERIUM 

The  tumour  may  inflame  from  the  bruising  it  has 
received  during  the  birth  of  the  child  or  from  extension  of 
intra-uterine  sepsis,  and  its  pedicle  is  especially  liable  to 
twist  owing  to  the  laxity  of  the  abdominal  wall  and  the 
mobility  of  the  abdominal  contents. 

Treatment. — As  a  rule,  if  the  patient  has  gone  through 
labour  safely,  there  is  no  necessity  to  interfere  with  the 
tumour  until  she  is  convalescent,  but  if  during  the  lying-in 
any  of  the  above  complications  arise,  the  tumour  must  be 
removed  as  soon  as  possible. 

Solid  tumours. — The  foregoing  remarks  deal  with  solid 
and  cystic  tumours  of  the  ovary  as  a  whole,  but  it  is 
evident  that  those  which  are  especially  concerned  with 
rupture  and  tapping  need  not  be  considered  if  the  tumour 
should  be  a  solid  one. 


CHAPTER    XXVIII 

UTERINE    MYOMATA   COMPLICATING   PREG- 
NANCY,   LABOUR,  AND    THE    PUERPERIUM 

MYOMA  AND   PREGNANCY 

The  fact  that  a  myomatous  uterus  has  become  pregnant 
is,  considered  by  itself,  a  contra-indication  for  the  removal 
of  the  tumour,  because  (i)  the  life  of  the  child  has  to  be 
considered,  and  (2)  the  operation  would  probably  involve 
the  removal  of  a  functional  organ.  Myomata  in  pregnancy 
should,  therefore,  not  be  operated  upon  except  for  urgent 
symptoms,  or  at  term  in  reasonable  anticipation  of  obstruc- 
tion to  delivery  or  trouble  during  the  puerperium.  There  can 
be  no  doubt  that  the  urgent  need  for  the  removal  of  myomata 
during  pregnancy  rarely  arises,  since  (1)  the  commonest 
reason  for  the  removal  of  myomata,  namely  menorrhagia, 
is  absent  ;  (2)  the  myomata  are  usually  subserous,  and  the 
least  likely  of  all  the  varieties  to  undergo  degenerative 
changes  ;  (3)  the  elevation  of  the  tumour  out  of  the  pelvis 
due  to  pregnancy  lessens  the  risk  of  pelvic  pressure  symptoms. 

Myomata  complicating  pregnancy,  however,  sometimes 
need  operative  treatment  on  account  of  symptoms  produced 
by  degeneration,  by  torsion,  by  pressure,  or  because  their 
situation  or  size  would  imperil  delivery. 

There  is  one  form  of  degeneration  of  a  myoma,  namely, 
red  necrobiosis,  which  is  frequently  associated  with  preg- 
nancy. In  this  condition  the  tumour  becomes  very  tender 
and  painful,  the  temperature  rises,  and  there  is  distinct 
enlargement  of  the  growth. 

Torsion  of  a  myoma  is  uncommon.  It  occurs  more 
often  in  connexion  with  pregnancy  or  puerpery  than  at  any 
other  time,  because  of  the  softness  of  the  uterine  tissue. 

5i6 


MYOMA  AND  PREGNANCY  517 

The  twist  usually  affects  the  pedicle  only,  but  exceptionally 
the  whole  uterus  may  be  rotated. 

Myomata,  particularly  of  the  posterior  wall,  may  retro- 
vert  the  pregnant  uterus  and  incarcerate  it  in  the  pelvis. 
Pedunculated  myomata  may  also  fall  into  the  pelvis  and 
impact,  whilst  the  hypertrophy  of  the  muscle-tissue  sur- 
rounding a  cervical  myoma  may  so  enlarge  the  mass  as 
to  cause  dangerous  pressure  symptoms. 

Lastly,  although  the  tumour  may  be  situated  above 
the  pelvic  brim,  its  size,  together  with  that  of  the  gravid 
uterus,  may  be  sufficient  to  produce  such  a  degree  of  abdo- 
minal distension  that  relief  becomes  urgent.  It  is  well 
known  that  myomata  situated  by  the  side  of  or  even  below 
the  head  may  during  labour  be  displaced  upwards  by  the 
retracting  uterine  muscle,  so  that  the  delivery  is  terminated 
in  safety,  but  we  are  of  opinion  that  it  is  very  unwise  to 
await  this  event,  for,  even  though  it  happen,  the  tumour 
may  be  so  bruised  in  the  process  that  septic  necrosis  will 
subsequently  occur.  If,  then,  at  term  the  tumour  is  in 
the  pelvis,  operative  treatment  should  be  undertaken. 

Treatment.  i.  Degeneration. — -If  urgent  symptoms 
of  degeneration  appear,  the  abdominal  cavity  must  be 
opened.  Except  on  the  rare  occasions  in  which  it  is  found 
possible  safely  to  enucleate  or  ligature  the  degenerating 
tumour,  the  uterus  should  be  removed  by  a  subtotal  hys- 
terectomy, the  child,  if  viable,  being  first  delivered  by 
Csesarean  section. 

ii.  Pressure. — The  pressure  may  be  due  either  to  the 
pelvic  environment  of  the  tumour  or  to  its  mere  bulk. 
If  the  pressure  symptoms  are  due  to  the  incarceration  of  a 
retro  verted  gravid  myomatous  uterus,  and  can  be  relieved 
by  rectifying  the  displacement  under  an  anaesthetic,  this 
should  be  done.  But  in  all  other  cases  of  pelvic  impaction, 
and  in  all  cases  of  myomata  situated  in  the  abdomen  and 
giving  rise  to  pressure  symptoms,  the  abdomen  should  be 
opened  and  the  tumour  removed,  with  or  without  the 
uterus.     In   such    instances    there    is    a    better   chance    of 


518  GYNECOLOGICAL  SURGERY 

conserving  the  uterus  than  when  the  symptoms  are  due  to 
degeneration,  because  in  a  good  number  of  these  cases  the 
tumours  are  pedunculated. 

iii.  Torsion. — The  abdominal  cavity  must  be  opened, 
and  if  the  torsion  merely  involves  the  pedicle,  the  surgeon 
should  be  able  to  remove  the  tumour  and  leave  the  uterus  ; 
but  if  the  latter  itself  is  twisted,  it  will  probably  have  to 
be  removed  as  well,  Caesarean  section  being  first  performed 
if  the  child  is  viable. 

iv.  Anticipation  at  term  of  obstruction  to  delivery,  or 
of  trouble  in  the  puerperium. — Choosing  a  date  a  few 
days  before  labour  is  expected,  the  abdomen  should  be 
opened  and  the  condition  investigated.  If  the  tumour  is 
pedunculated,  and  if  it  is  solitary  or  there  are  no  others 
of  importance  present,  it  should  be  possible  to  displace 
it  from  the  pelvis  and  ligate  it  off,  the  abdominal  wound 
then  being  closed  and  pregnancy  allowed  to  terminate 
naturally.  If,  on  the  other  hand,  the  tumour  is  so  situ- 
ated that  it  is  impossible  to  carry  out  this  treatment,  or  if, 
being  pedunculated,  there  are  yet-  other  large  tumours 
present,  Caesarean  section  is  indicated,  followed  by  hystero- 
myomectomy. 

Myomectomy  or  hysterectomy — The  ideal  treatment 
is  to  remove  the  myoma  only,  and  allow  the  pregnancy  to 
continue.  This  is  usually  possible  with  pedunculated 
subperitoneal  tumours.  The  enucleation  of  sessile  tumours 
is  commonly  followed  by  such  haemorrhage  as  compels  the 
removal  of  the  uterus  ;  while  in  the  event  of  its  being  able 
to  be  controlled  by  ligatures  the  likelihood  of  miscarriage 
or  premature  labour  is  very  great. 

It  is  particularly  to  be  remembered  that  owing  to  the 
softness  of  the  wall  of  the  pregnant  uterus  a  sessile  tumour 
may  give  the  impression  of  being  pedunculated  before  the 
abdomen  is  opened. 

Where  myomectomy  has  been  performed  the  patient 
should  be  kept  under  the  influence  of  morphia  as  described 
on  p.  513.     The  remarks  there  made  on  the  necessity  for 


MYOMA  AND   LABOUR  519 

firm  closure  of  the  abdominal  wound  are  equally  applicable 
here. 

MYOMA  AND   LABOUR 

For  operating  upon  a  myoma  in  labour  the  indications 
are  obstruction  and  haemorrhage. 

Obstruction. — This  may  be  due  to — 
i.  A  submucous  myoma  situated  below  the  presenting 

part, 
ii.  A  subperitoneal  myoma  below  the  presenting  part. 

hi.  Interstitial  and  cervical  myomata. 

iv.  A  broad-ligament  myoma. 

Treatment,  i.  Submucous  myoma. — If  this  is  poly- 
poid in  form  and  protruding  below  the  head  of  the  child, 
the  stalk  should  be  cut  through  and  the  tumour  removed, 
after  which  the  labour  may  be  allowed  to  proceed.  If  the 
tumour  is  sessile  and  small  and  projecting  into  the  cervical 
canal  below  the  child's  head,  its  capsule  should  be  incised 
and  it  should  be  enucleated.  If  the  tumour  is  too  large 
safely  to  follow  this  procedure,  Caesarean  section  followed 
by  hystero-myomectomy  is  the  proper  course. 

ii.  Subperitoneal  myoma. — If,  the  patient  being  under 
anaesthesia,  the  tumour  is  pedunculated,  one  may  be  able 
to  push  it  above  the  presenting  part  at  once  and  without 
difficulty.  If  so,  this  should  be  done,  and  the  child  delivered 
with  forceps.  It  cannot  be  denied  that  there  is  a  certain 
element  of  danger  in  this  treatment.  We  remember  a  case 
in  which  the  tumour  was  displaced  with  ease,  and  yet, 
becoming  necrosed,  killed  the  patient  within  a  week. 
Further,  the  tumour  may  be  an  ovarian  cyst,  and  may  be 
ruptured  in  the  process.  These  risks,  however,  are  much 
less  than  those  of  performing  an  abdominal  section,  and 
perhaps  a  Caesarean  delivery,  in  a  patient  unprepared,  and 
who  probably  has  been  already  subjected  to  prolonged 
efforts  at  delivery. 

In  following  the  treatment  recommended,  the  medical 
attendant  should  keep  a  very  careful  watch  on  the  patient, 
and  if  the  tumour  subsequently  causes  any  bad  symptoms 


520  GYNAECOLOGICAL  SURGERY 

it  should  be  at  once  removed  ;  otherwise  it  may  be  left 
to  be  dealt  with  when  the  patient  is  convalescent. 

If  the  tumour  cannot  be  pushed  up,  the  abdomen  must 
be  opened  and  Csesarean  hysterectomy  performed. 

iii.  and  iv.  Interstitial,  cervical  and  broad-ligament  myo- 
mata. — The  abdomen  must  be  opened,  Csesarean  section  per- 
formed, and  the  tumour  removed  with  or  without  the  uterus. 

Haemorrhage.  —  Cases  are  on  record  where  intraperi- 
toneal bleeding  has  occurred  during  labour  from  omentum 
having  been  torn  off  the  surface  of  a  uterine  myoma  to 
which  it  was  previously  adherent.  In  such  circumstances 
abdominal  section  would  at  once  be  indicated. 

MYOMA  AND   THE  PUERPERIUM 

After  labour  or  miscarriage,  uterine  myomata  may 
imperil  life  on  account  of  infection,  degeneration,  pressure, 
torsion,  or  extrusion. 

Infection  may  result  from  bruising  during  delivery  or 
the  introduction  of  septic  organisms  into  the  cavity  of 
the  uterus.  Of  the  various  forms  of  degeneration  that 
may  occur,  red  necrobiosis  is  the  commonest.  Pressure 
may  be  due  to  the  sinking  down  of  the  tumour  into  the 
pelvis  after  the  uterus  has  emptied  itself.  Torsion  occa- 
sionally occurs  owing  to  the  alteration  of  its  intra-abdominal 
relations  following  retraction  of  the  uterus.  Extrusion  is 
probably  primarily  due  to  intra-uterine  sepsis  causing 
ulceration  of  the  capsule  of  the  tumour. 

Treatments — Infection,  degeneration,  pressure,  torsion, 
must  all  be  dealt  with  by  abdominal  section.  In  the  first, 
total  hysterectomy  will  be  needed,  with  drainage  of  the 
pelvic  cavity.  In  the  second,  subtotal  hysterectomy  will 
probably  suffice.  In  pressure  or  torsion,  it  is  likely  that 
subtotal  hysterectomy  will  be  required,  but  on  occasion 
it  may  be  possible  to  save  the  uterus  whilst  removing 
the  tumour. 

Extrusion,  being  always  a  septic  process,  should  be 
dealt  with  by  vaginal  enucleation. 


CHAPTER    XXIX 

CANCER    OF   THE    CERVIX   UTERI    COMPLICAT- 
ING   PREGNANCY    AND    LABOUR 

COMPLICATING  PREGNANCY 

The  treatment  may  be  divided  into  four  classes  : 

i.  When  the  cancer  is  operable  and  the  child  is  not  viable. 

2.  When  the  cancer  is  operable  and  the  child  is  viable. 

3.  When    the    cancer    is    inoperable    and    the    child    is 

not  viable. 

4.  When    the    cancer    is    inoperable    and    the    child    is 

viable. 

1.  Cancer  operable  and  child  not  viable. — The  best 
treatment  is  the  radical  extirpation  after  Wertheim's 
method. 

An  alternative  but  not  so  good  a  method  is  to  remove 
the  uterus  by  vaginal  hysterectomy,  and  to  evacuate  its 
contents  during  the  operation,  if  necessary. 

2.  Cancer  operable  and  child  viable.  —  The  proper 
treatment  is  a  Csesarean  section,  followed  by  radical  ab- 
dominal extirpation,  which  in  these  circumstances  is  easier 
than  usual. 

An  alternative  but  much  inferior  method  of  treatment  is 
to  induce  labour  and  remove  the  uterus  subsequently,  either 
by  the  radical  method  or  by  vaginal  hysterectomy. 

3.  Cancer  inoperable  and  child  not  viable. — It  is  very 
difficult  to  give  a  decided  opinion  as  to  the  correct  treat- 
ment in  this  case.  Various  factors  have  to  be  taken  into 
consideration.  If  abdominal  examination  disclosed  that 
the  patient  was  not  more  than  three  months  pregnant,  un- 
doubtedly the  proper  treatment  would  be  to  evacuate  the 
uterus   and  thoroughly  scrape   and   cauterize   the   growth. 

521 


522  GYNAECOLOGICAL  SURGERY 

We  think  this  to  be  the  proper  treatment,  because — 
(i)  It  is  unlikely  that  the  patient  will  live  to  the  practical 
viability  of  the  child  if  the  case,  when  it  comes  under 
treatment,  is  already  inoperable  by  the  modern  standard 
(pp.  376-78).  (2)  The  presence  of  the  pregnancy  accelerates 
the  growth  and  makes  the  haemorrhage  much  worse. 
(3)  Pregnancy  itself  means  the  supervention  of  a  good  deal 
of  additional  distress.  (4)  Scraping  and  cauterization,  which 
have  undoubtedly  a  retarding  effect  on  many  cases  of 
carcinoma  of  the  cervix,  cannot  be  done  till  the  uterus  is 
evacuated. 

If  the  pregnancy  is  not  discovered  until  after  the  third 
month,  we  think  it  should  be  allowed  to  go  on  till  the 
child  is  viable,  (1)  because  the  evacuation  of  the  uterus 
would  be  a  much  more  difficult  and  dangerous  or  even 
impossible  proceeding,  and  (2)  because  there  is  a  better 
chance  of  the  child  surviving  to  viability. 

4.  Cancer  inoperable  and  child  viable.  —  The  child 
must  be  delivered  by  Cesarean  section,  after  which  it  is 
better,  in  the  mother's  interest,  to  remove  the  body  of  the 
uterus  because  of  its  liability  to  infection  during  the  puer- 
perium.  The  hysterectomy  is  therefore  subtotal,  and 
some  surgeons  have  suggested  that  the  best  treatment, 
so  as  to  avoid  peritoneal  infection,  would  be  to  fix  the 
stump  in  the  abdominal  wound  after  the  method  of  Porro, 
but  without  the  gross  method  of  clamping  en  masse  origin- 
ally used  in  this  proceeding. 

COMPLICATING    LABOUR 

The  treatment  may  be  divided  into  three  classes  : 

1.  Cancer  operable. 

2.  Cancer  inoperable,  child  alive. 

3.  Cancer  inoperable,  child  dead. 

1.  Cancer  operable. —  If  the  patient  is  in  the  first 
stage  of  labour,  that  is  when  the  os  is  not  yet  fully  dilated 
and  the  presenting  part  is  still  in  the  uterus,  the  proper 
treatment  is  a  Csesarean  section,  followed  by  radical  extir- 


CANCER  OF  CERVIX  AND  LABOUR       523 

pation.  An  alternative  but  inferior  treatment  would  be  to 
allow  the  labour  to  terminate  naturally,  and  subsequently 
to  remove  the  uterus  by  vaginal  hysterectomy. 

If  the  presenting  part  has  come  through  the  cervix 
and  is  in  the  vagina,  then  the  labour  must  be  allowed  to 
terminate  and  the  uterus  be  subsequently  removed  by  a 
radical  extirpation,  or,  failing  this,  a  vaginal  hysterectomy. 

2.  Cancer  inoperable,  child  alive. — The  treatment  of 
this  condition  is  the  same  as  that  indicated  in  the  para- 
graph dealing  with  a  similar  state  of  things  in  the  later 
months  of  pregnancy,  p.  522. 

3.  Cancer  inoperable,  child  dead. — The  difficulty  in 
this  case  is  to  secure  enough  dilatation  of  the  cervix  to 
deliver  the  child,  craniotomy  having  first  been  performed. 
Owing  to  the  injury  caused  to  the  parts  during  delivery, 
sloughing  may  take  place,  the  patient  subsequently  dying 
of  septicaemia.  If,  therefore,  it  is  obvious  that  sufficient 
dilatation  of  the  cervix  cannot  be  secured  to  allow  the 
crushed  head  to  pass  without  great  bruising  and  laceration, 
it  will  be  safer  to  remove  the  child  by  Csesarean  section 
and  the  body  of  the  uterus  by  a  supravaginal  hysterectomy, 
as  previously  described. 


CHAPTER    XXX 
OPERATIONS    ON   THE   INTESTINAL   CANAL 

I.     APPENDICEGTOMY 

Sometimes,  when  the  abdominal  cavity  is  opened  prepara- 
tory to  the  removal  of  a  diseased  Fallopian  tube,  ovary, 
or  uterus,  the  appendix  is  found  to  be  so  diseased  or  so 
adherent  to  the  diseased  structure  that  its  removal  is 
imperative.  At  other  times  the  appendix  may  be  found 
to  be  the  sole  cause  of  the  symptoms  previously  supposed 
to  be  due  to  some  disease  of  the  genital  organs. 

Instruments. — Among  the  instruments  prepared  for  the 
primary  operation  will  be  found  those  necessary  for  remov- 
ing the  appendix. 

Operation,  i.  Opening  the  abdominal  cavity- — In  most 
cases  a  middle-line  incision  has  been  employed,  and,  as 
a  rule,  the  appendix  can  be  removed  very  well  through 
such  an  opening.  It  may  be  necessary  in  some  cases  to 
make  an  additional  opening  over  the  appendix. 

ii.  Clamping  and  dividing  the  meso-appendix. — Any 
adhesions  present  having  been  separated,  and  the  appendix 
having  been  pulled  up  and  steadied,  its  mesentery  is  clamped 
by  pressure-forceps,  the  vessels  being  thus  temporarily 
secured.  The  mesentery  is  then  divided  throughout  its 
whole  length  up  to  the  caecum,  and  the  appendix  is  set  free 
(Fig.  358)- 

iii.  Amputating  the  appendix.  —  A  ligature  of  No.  2 
silk  is  passed  round  the  appendix  at  its  junction  with  the 
caecum.  The  ligature  having  been  tied,  the  appendix  is 
amputated  about  one-eighth  of  an  inch  above  the  ligature 
(Fig.  359).  The  stump  is  then  touched  with  pure  carbolic 
acid. 

524 


APPENDIGEGTOMY 


525 


iv.  Burying  the  stump. — -A  purse-string  suture  passed 
through  the  serous  and  muscular  coats  of  the  caecum  is 
made  to  surround  the  stump  of  the  appendix,  and  as  this 
is  pulled  tight,  the  latter  is  invaginated  by  an  assistant 
with  the  aid  of  the  forceps,  so  that  it  is  entirely  buried. 

The  vessels  in  the  mesentery  are  secured  with  ligatures 
of  No.  2  silk  (Fig.  360). 

Dangers. — When    amputating    the    appendix,    faecal   or 


Fig.  358. — Appendicectomy  :    Dividing  the 
meso-appendix. 


purulent  matter  may  escape,  so  that  the  field  of  operation 
should  always  be  carefully  packed  off  with  swabs. 

Dressing  and  after-treatment.  —  See  Chapter  xxxn. 
In  cases  of  chronic  appendicitis,  no  drainage  is  necessary, 
but  where  a  pyo-appendix  has  been  removed  and  the  sur- 
rounding peritoneum  has  possibly  been  contaminated  with 
pus,  it  is  better  to  leave  a  very  small  drainage-tube  down 
to  the  stump  for  forty-eight  hours.  Where  a  local  peritoneal 
abscess  is  present  it  should  always  be  evacuated  and 
drained  by  a  large  tube  through  an  iliac  incision,  the  median 


526 


GYNAECOLOGICAL  SURGERY 


abdominal  incision  having  been  previously  closed,  unless 
the  pus  has  extended  into  the  pelvis,  in  which  case  the 
incision  should  be  utilized  to  drain  the  pelvic  cavity 
separately. 

Lastly,   if   diffuse   peritonitis   is   present,    the   appendix 
should  be  removed  by  means  of  a  right  iliac  incision,  through 

which  a  large  tube 
is  subsequently 
inserted  down  to 
the  site  of  the 
stump.  The  pel- 
vis should  then  be 
drained  through 
the  median  inci- 
sion, and  in  most 
cases  a  third  open- 
ing is  also  made 
into  the  right  lum- 
bar pouch,  so  as 
to  obviate  the  ex- 
tension of  pus  be- 
hind the  ascending 
colon  and  the  for- 
mation of  a  sub- 
phrenic abscess. 
Finally,  in  a  few 
cases  of  complete 
general  peritonitis, 
drainage  incision 
should  also  be 
made  into  the  left 
iliac  and  left  lumbar  pouches.  The  patient  should  be 
propped  well  up  as  soon  as  possible  after  the  operation. 

II.    ENTERECTOMY 

During  the  course  of  an  operation  on  the  female  genital 
organs  it  may  be  found   necessary  to    excise  a  portion  of 


Fig.  359. — Ligaturing  the  base  of 
the  appendix. 


ENTERECTOMY 


527 


the  intestine,  owing  to  its  adhesion  to  some  growth  and 
the  impossibility  of  freeing  it. 

Again,  an  operation  may  be  started  on  the  assumption 
that  a  growth  felt  per   abdomen   or   per  vaginam  is  gynae- 


Fig.  360. — Invaginating  the 
stump. 

cological  in  nature,  but  when  the  abdominal  cavity  is 
opened  it  is  found  that  the  mass  represents  malignant 
disease  of  the  bowel,  and  that  the  only  proper  treatment  is 
enterectomy.  We  shall  only  describe  the  method  of  end- 
to-end  anastomosis,  which,  in  our  opinion,  is  the  best  in 
the  large  majority  of  cases. 


528 


GYNAECOLOGICAL  SURGERY 


Operation,  i.  Excising  the  bowel. — The  loop  of  bowel 
containing  the  growth  having  been  drawn  well  up  into  the 
wound,  the  abdominal  contents  are  carefully  packed  off 
with  gauze  and  two  pairs  of  bowel  clamps  and  two  pairs 
of  ring  forceps  are  applied  as  follows  :  one  pair  of  ring 
forceps  on  each  side  of  the  growth  but  well  free  of  it,  and 
one  pair  of  bowel  clamps  3  in.  farther  from  the  growth  on 


Fig.  361. — Enterectomy  :  Excision  of 
the  diseased  segment  of  bowel. 

either  side  of  the  others.  The  mesentery  should  not  be  in- 
cluded in  the  clamps.  The  bowel  is  then  divided  with 
scissors  between  the  ring  forceps  and  the  clamp  on  each 
side  of  the  growth  (Fig.  361)  (the  contents  of  the  excised 
portion  being  thus  prevented  from  escaping),  together  with 
a  V-shaped  portion  of  the  mesentery  corresponding  to  the 
portion  of  bowel  excised. 

ii.  Ligaturing  the  mesenteric  vessels  and  emptying  the 
proximal  portion  of  the  bowel. — All  bleeding-points  in 
the  mesentery  are  secured  with  pressure-forceps  and  liga- 
tured with  No.  2  silk.     If  the  portion  of  bowel  resected  is 


ENTEREGTOMY 


529 


distal  to  the  hepatic  flexure  of  the  colon,  it  will  usually 
be  found  that  the  bowel  above  it  is  loaded  with  retained 
scybala,  and  it  is  most  essential  that  these  should  be 
removed  before  the  anastomosis  is  proceeded  with,  or  their 
passage  will  subsequently  endanger  the  integrity  of  the 
suture-line.     Having,  therefore,  most  carefully  covered  up 


OPT  — - : 


Fig.  362. — Emptying  the  upper  bowel. 


everything  with  sterilized  cloths  except  the  proximal  portion 
of  bowel,  the  surgeon  proceeds  to  remove  the  clamp  securing 
its  cut  end  and  "  milks  "  the  intestinal  contents  into  a 
porringer  (Fig.  362).  The  clamp  is  then  reapplied  to  this 
portion  of  intestine  about  2  in.  from  its  cut  end,  and  the 
parts  are  carefully  washed  with  sterile  saline  solution. 

iii.    Trimming    the    cut    ends    of   the    intestine. — The 
mucous  coat  of  the  cut  ends  will  be  found  somewhat  ragged 
and  excessive,  and  this  should  be  trimmed  up  so  that  it 
is  flush  with  the  muscular  coat  (Fig.  363). 
2  1 


530 


GYNECOLOGICAL  SURGERY 


iv.  Anchoring  the  cut  ends. — A  suture  of  No.  I  silk 
is  passed  through  the  mesentery  of  each  piece  of  intestine 
just  at  the  point  where  it  joins  the  bowel,  and  tied  (Fig. 
364),  the  ends  of  the  suture  being  left  long. 

v.  Applying  the  first  row  of  sutures. — The  bowel-ends 
are  approximated  as  nearly  as  possible.  The  mucous  mem- 
brane and  the  muscular  coats  of  the  cut  ends  of  the  intestine 
are  joined  with  a  continuous  suture  of  No.  1  silk,  beginning 


1     1 


Fig.  363. — Trimming  the  edges  of  the  bowel. 


at  the  middle  point  of  the  lateral  margin  of  the  cut  lumen 
on  the  side  opposite  to  the  operator,  and  being  carried 
towards  him  across  the  situation  of  the  mesenteric  attach- 
ment to  a  similar  point  on  his  own  side  (Fig.  365).  The 
integrity  of  the  mesenteric  half  of  the  bowel  lumen  being 
thus  restored,  the  suture  is  carried  round  its  remaining 
half.  In  order  to  do  this  the  needle,  after  having  been 
passed  through  the  operator's  right-hand  edge  of  the  bowel 
from  within  outwards,  is  reversed  in  the  forceps  and  pene- 
trates the  edge  to  the  left  hand  of  the  operator  from  without 
inwards,  and  is  so  continued  until  it  meets  with  the  loose 


ENTEREGTOMY 


53i 


Fig.  364. — Tying  the  anchoring  suture. 


Fig.  365. — Applying  the  first  half  of  the  first-row  suture, 


532 


GYNAECOLOGICAL  SURGERY 


end  of  the  suture  at  the  point  where  the  stitching  was 
first  begun,  i.e.  at  the  middle  point  of  the  lateral  wall 
farthest  from  the  operator  (Fig.  366).  The  two  ends  of 
the  suture  are  then  tied.  By  adopting  this  method  the 
first-row  suture  is  more  securely  finished  off  than  if  it 
were  begun  at  the  point  of  mesenteric  attachment. 

vi.  Second   row   of  sutures. — One    of   the  ends   of   the 


Fig.  366. — Applying  the  second  half  of  the  first-row  suture. 

suture  that  anchored  the  two  pieces  of  mesentery  together 
is  threaded  on  a  needle,  and  the  peritoneum  is  continuously 
stitched  by  Lembert's  method  right  round  the  lumen  of 
the  bowel  till  the  other  end  of  the  suture  is  reached,  to 
which  it  is  tied  (Fig.  367). 

vii.  Third  row  of  sutures. — Some  operators  are  satis- 
fied in  any  case  with  two  rows  of  sutures,  but  it  has  always 
been  our  practice,  when  dealing  with  these  cases,  to  insert 
a  third  row  of  interrupted  Lembert  sutures  of  No.  1  silk, 
which,  when  tied,  completely  bury  the  second  row  of 
sutures  (Fig.  368). 


ENTERECTOMY 


533 


Fig.  367. — Applying  the  second-row  suture. 


Fig.  368. — Applying  the  third-row  suture. 


534  GYNECOLOGICAL  SURGERY 

The  gap  in  the  mesentery  is  closed  with  two  or  three 
interrupted  silk  sutures.  Care  must  be  taken  not  to  include 
a  vessel  in  them,  especially  in  the  small  intestine,  for  fear 
of  injuring  the  blood-supply  to  the  bowel. 

viii.  Closing  the  abdominal  wound. — The  anastomosis 
should  now  be  carefully  examined  for  any  gaps  or  loose 
sutures,  and,  none  being  found,  it  should  be  freely  washed 
with  warm  saline  solution,  after  which  the  abdominal 
wound  should  be  closed  after  the  method  described  on 
p.  285.  Where  there  is  any  doubt  as  to  the  suture-line 
holding,  a  very  small  tube  should  be  inserted  down  to  the 
involved  coil  for  two  or  three  days. 

After-treatment.  —  It  has  been  our  practice  to  treat 
these  cases  by  abstention  from  food  of  any  sort  for  a  week, 
maintaining  the  strength  and  alleviating  the  thirst  by  four- 
hourly  rectal  injections  of  from  6  to  10  ounces  of  warm 
saline  solution. 

Our  colleagues  on  the  medical  side  at  the  Middlesex 
Hospital  have  conclusively  shown  that  it  is  possible  to 
maintain  patients  on  this  treatment,  and  this  alone,  for 
several  weeks,  and  our  cases  of  intestinal  resection  have 
amply  confirmed  it.  After  the  first  forty-eight  hours  we 
allow  water  to  be  given  by  the  mouth  in  moderate  quan- 
tities as  well.  At  the  end  of  a  week,  mouth-feeding  is  begun, 
and  after  a  couple  of  days  the  bowels  are  opened  by  an 
enema.  This  treatment  has  proved  very  successful,  and  all 
our  patients  have  recovered  most  satisfactorily. 

In  other  respects  the  general  lines  of  the  after-treatment 
of  these  cases  are  the  same  as  those  described  at  p.  44 
and  Chapter  xxxn. 

Difficulties.  —  The  operation  of  intestinal  anastomosis 
is,  as  a  rule,  extremely  simple  and,  when  not  performed 
in  conditions  of  acute  intestinal  obstruction,  very  success- 
ful. On  occasions,  however,  its  performance  is  difficult, 
as  when  the  loop  of  gut  cannot  be  brought  out  of  the 
wound  owing  to  shortness  of  the  mesentery.  In  other 
cases   the   lumens   of   the  upper  and  lower  ends  of  intes- 


GOLOTOMY  535 

tine  are  of  different  size,  as,  for  instance,  after  resection 
of  the  caecum. 

In  these  circumstances  the  larger  end  may  be  partly 
closed  with  sutures  until  the  aperture  approximates  to 
that  of  the  smaller  end,  when  the  anastomosis  may  be 
proceeded  with  on  the  lines  indicated.  Or  it  may  be  pre- 
ferred to  close  the  bowel-ends  and  perform  lateral  anasto- 
mosis. Or,  lastly,  the  larger  end  only  may  be  closed 
and  the  smaller  end  be  laterally  implanted. 

In  all  cases  when  possible  the  anastomosed  coil  should 
be  left  immediately  under  the  abdominal  wound,  and  where 
from  any  reason  the  suture-line  is  likely  to  yield  a  drainage- 
tube  should  be  inserted  as  previously  advised. 

III.    COLOTOMY 

The  gynaecological  surgeon  finds  himself  occasionally 
called  upon  to  perform  colotomy  in  such  circumstances  as 
an  irremovable  pelvic  tumour  with  intestinal  obstruction. 
The  various  methods  of  performing  this  operation  are 
described  at  length  in  text-books  devoted  to  general  sur- 
gery. We  shall  here  content  ourselves  with  a  description 
of  the  method  we  ourselves  employ. 

Preparation  of  the  patient. — See  pp.  82-86. 

Position.  — ■  The  patient  should  lie  in  the  horizontal 
position. 

Instruments. — See  p.  276.  In  addition  a  Paul's  tube 
will  be  required  if  the  bowel  is  to  be  immediately  opened. 

Operation,  i.  Opening  the  abdominal  cavity. — As  in 
most  cases  the  abdomen  will  have  already  been  opened  in 
the  middle  line,  it  will  be  necessary  to  make  an  additional 
/  opening  over  that  portion  of  the  bowel  which  it  is  intended  to 
bring  to  the  surface.  In  the  ordinary  left  inguinal  colotomy 
this  will  be  parallel  with  Poupart's  ligament,  and  the 
upper  end  will  be  at  a  point  at  the  junction  of  the  outer 
and  middle  third  of  a  line  joining  the  anterior  superior 
spine  and  the  umbilicus. 

ii.  Anchoring  the  loop  of  intestine. — The  large  intestine 


536 


GYNAECOLOGICAL  SURGERY 


Fig.  369.— Golotomy  : 

Anchoring    the 

mesentery. 

of  interrupted  silk  sutures 
wound  and  the  peri- 
toneal and  muscular 
coats  of  the  intestine, 
iv.  Insertion  of 
purse -string  suture 
in  the  bowel.  ■ — •  If 
immediate  opening 
of  the  bowel  is  neces- 
sary, a  purse-string 
suture  is  applied  well 
outside  the  area  of 
the  contemplated 
aperture,  and  the 
bowel  is  incised  with 
a  scalpel  for  about 
three-quarters  of  an 
inch  (Fig.  371). 


presents  at  the  wound, 
and  a  piece  of  it  is 
pulled  up  and  anchored 
to  the  fascia  by  pass- 
ing a  mattress  -  suture 
through  the  mesentery 
and  the  fascia  on  both 
sides  (Fig.  369),  after 
which  the  intestine  is 
tethered  to  the  upper 
and  lower  angles  of  the 
wound  by  silk  sutures 
passed  through  the  fascia 
and  muscular  coat  of 
the  bowel  (Fig.  370). 

iii.    Suture      of      the 
bowel  to  the  skin. — The 
bowel  is  sutured  to  the 
skin  all  round  by  a  series 
that  includes  the  skin  of    the 


Fig.  370.— Anchor- 
ing the  bowel. 


GOLOTOMY 


537 


v.  Insertion  of  Paul's  tube.— Paul's  tube,  with  a  long 
piece  of  india-rubber  tubing  affixed,  is  rapidly  inserted 
through  the  hole  made  by  the 
scalpel,  and  the  purse-string  su- 
ture is  then  drawn  tight,  so  that 
the  tube  is  fixed  securely  in  the 
bowel  (Fig.  372). 

Dressing. — Large  pads  of  ab- 
sorbent wool  are  placed  over  the 
wound,  and  are  kept  in  place  by 
a  bandage.  The  india-rubber 
tube  is  led  away  into  a  recep- 
tacle under  the  bed. 

After-treatment. — See  Chap- 
ter xxxii.  The  tube  is  re- 
moved about  the  fourth  day, 
after  which  the  wound  is  dressed 
often    as    the    action    of    the 


as 

bowels     may    render    necessary. 

The     skin    should     be    carefully 


Fig.  371.— Open- 
ing the  bowel. 


Fig.  372.— In- 
serting Paul's 
tube. 


538  GYNAECOLOGICAL  SURGERY 

washed  with  soap  and  water  whenever  this  is  done,  and 
should  be  protected  by  smearing  it  with  a  mixture  of 
zinc  ointment  and  vaseline.  The  skin  sutures  should  be 
removed  at  the  end  of  a  week. 

IV.    C.ECOSTOMY 

This  operation  is  occasionally  called  for  in  conditions  of 
acute  intestinal  obstruction  where  the  exact  site  of  the 
obstruction  is  unknown  except  that  it  is  somewhere  in 
the  large  intestine,  and  where  the  condition  of  the  patient 
is  such  that  an  exploratory  cceliotomy  is  not  advisable.  In 
these  circumstances  the  operation  is  remarkably  successful 
and  can  be  performed  very  quickly. 

Preparation  of  the  patient. — See  pp.  82-86.  As  the 
operation  has  usually  to  be  performed  in  emergency,  the 
opportunity  for  preoperative  preparation  is  limited  to 
the  short  period  on  the  table  before  operation. 

Position. — The  patient  will  be  in  the  dorsal  position. 

Instruments. — -A  scalpel,  a  dissecting  forceps,  two  pres- 
sure-forceps, and  a  couple  of  curved  needles  No.  7. 

Operation,  i.  Opening  the  abdominal  cavity.  —  The 
incision,  unlike  that  of  colotomy,  should  be  made  close  to 
the  right  anterior  superior  iliac  spine.  It  should  be  short, 
have  its  centre  at  this  point,  and  lie  parallel  to  the  direction 
of  the  fibres  of  the  external  oblique. 

ii.  Suturing  the  bowel. — In  such  a  case  as  we  describe, 
the  distended  caecum  immediately  protrudes  through  the 
parietal  wound,  to  each  end  of  which  it  should  be  secured 
by  a  suture  of  No.  4  silk  passed  through  the  skin  and 
fascia  on  both  sides  of  the  wound  and  the  muscular  and 
serous  coats  of  the  bowel.  Two  lateral  mattress-sutures 
should  be  applied,  one  on  each  side,  picking  up  the  skin 
and  fascia  and  serous  and  muscular  coats  of  the  bowel. 
A  small  opening  should  then  be  made  in  the  bowel  by 
stabbing  it  with  the  point  of  a  scalpel. 

After-treatment. — As  for  colotomy.  The  sutures  should 
6e  removed  at  the  end  of  ten  days. 


CHAPTER    XXXI 

OPERATION-WOUNDS    OF   THE    BLADDER, 
URETER,    AND   BOWEL 

I.   WOUNDS    OF    THE    BLADDER 

During  operations  on  the  pelvic  organs,  and  more  parti- 
cularly those  having  for  their  object  the  removal  of  the 
uterus,  the  bladder  may  be  wounded. 

Wounds  of  the  bladder  may  be  divided  into  three  classes  : 
i.  The  peritoneal  covering  only  is  injured. 

2.  The  muscular  coat  is  injured. 

3.  All  the  coats  are  injured  and  the  bladder  is  opened. 

1.  Peritoneal  injury — The  cut  edges  of  the  peritoneum 
should  be  approximated  with  a  continuous  Lembert's  suture 
of  No.  1  silk. 

2.  Muscular  injury. — -The  divided  muscle  should  be 
united  with  interrupted  sutures  of  No.  1  silk,  and  the 
peritoneal  wound  then  closed  with  a  continuous  Lembert's 
suture  of  No.  1  silk. 

3.  The  bladder  is  opened. — -The  mucous  membrane 
should  first  be  united  with  a  continuous  suture  of  No.  1 
silk.  The  muscular  coat  should  then  be  united  by  inter- 
rupted sutures  of  No.  1  silk,  and,  lastly,  the  peritoneum 
is  closed  with  a  continuous  Lembert's  suture  of  No.  1 
silk.  In  some  cases  of  total  hysterectomy,  especially  in 
the  radical  operation  for  carcinoma  of  the  cervix,  the 
bladder  may  be  wounded  below  the  point  of  peritoneal 
reflection.  Very  often  in  these  circumstances  the  bladder- 
wall  is  so  thin  that  tier  sutures  are  impracticable.  In 
such  a  case  a  good  result  may  be  obtained  by  suturing  the 
upper  edge  of  the  wound  in  the  bladder  to  the  cut  lower 
edge  and  the  edge  of  the  anterior  vaginal  wall  inclusively. 

539 


540  GYNECOLOGICAL  SURGERY 

After-treatment.  —  A  catheter  may  either  be  tied  in 
and  left  in  situ  for  a  week,  or  it  may  be  passed  every  two 
hours  during  this  period.  Urotropin  or  salol,  5  grains 
three  times  a  day,  should  be  given  by  the  mouth. 

II.  IMPLANTATION  OF  THE  CUT  URETER  INTO 
THE  BLADDER 

During  some  operations  on  the  uterus  or  broad  liga- 
ment the  ureter  may  be  cut,  or  a  piece  of  it  may  have 
to  be  excised  on  account  of  malignant  disease  implicating 
it.  One  method  of  treating  this  complication  is  by  implant- 
ing the  end  of  the  cut  ureter  into  the  bladder. 

It  is  all-important  to  leave  intact  the  blood-supply  to 
the  ureter  derived  from  the  peritoneal  vessels.  No  loose 
end  of  ureter  free  of  peritoneal  attachment  should  there- 
fore be  utilized  for  the  implantation,  but  sufficient  of  the 
tube  should  be  deliberately  resected  as  far  as  its  lowest 
point  of  adhesion  to  the  peritoneum. 

The  implantation  having  been  performed,  the  cut  peri- 
toneal edge  of  the  posterior  layer  of  the  broad  ligament 
should  be  sutured  to  the  bladder  inside  the  point  of  anas- 
tomosis. By  this  means  the  ureter  is  left  covered  over 
entirely  by  peritoneum,  and  no  denuded  portion  is  running 
unsupported  across  the  pelvis  like  a  clothes-line.  The 
method  about  to  be  described  accomplishes  this  object. 

i.  Preparation  of  the  ureter. — The  proximal  cut  end  of 
the  ureter  is  ligated  with  No.  4  silk,  the  ends  of  the  ligature 
being  left  long  to  act  as  a  guide.  If  the  distal  end  of  the 
cut  ureter  can  be  seen,  it  also  should  be  ligated  and 
the  silk  cut  short  (Fig.  373). 

ii.  Preparation  of  the  bladder. — -An  opening  is  now 
made  into  the  bladder  through  its  peritoneal  surface  (Fig. 
374),  and,  the  index  finger  having  been  inserted,  a  second 
small  opening,  only  just  large  enough  to  pass  the  ureter 
through,  is  made  just  above  the  original  uretero-vesical 
junction.  This  should  be  effected  by  cutting  down  on  the 
tip  of  the  index  ringer  in  the  bladder  with  the  point  of  a 


OPERATION- WOUNDS 


54i 


scalpel.     This  opening  is  through  the  portion  of  the  vesical 
wall  not  covered  with  peritoneum  (Fig.  375), 


Fig.  373. — Placing  the  guide   ligature  on  the  proximal 
cut  end  of  the  ureter. 


iii.  Implanting   the   ureter. — The   proximal  end   of   the 
cut  ureter  is  now  pulled  into  the  bladder  by  threading  the 


Fig.  374. — Making  the  upper  opening  into  the  bladder. 


542 


GYNAECOLOGICAL  SURGERY 


guide  ligature  through  the  lower  opening  and  out  through 
the  upper  opening  (Fig.  376). 

iv.  Ensheathing  the  new  uretero-vesical  junction. — 
The  cut  edge  of  the  lateral  pelvic  peritoneum  to  which  the 
ureter  is  adherent  is  now  sutured  to  the  cut  edge  of  the 
peritoneum  covering  the  bladder,  and  below  this  directly 
to  the  vesical  wall.      With  a  little  ingenuity  a  complete 


Fig.  375. — Making  the  lower  opening  into  the  bladder. 


sheath  for  the  ureter  at  its  new  junction  with  the  bladder 
can  be  effected  (Fig.  377). 

v.  Anchoring  the  ureter. — The  ureter  projecting  into 
the  bladder  is  prevented  from  retracting  by  the  previous 
suture  of  the  peritoneum  to  which  it  is  attached  ;  but  to 
ensure  against  this  mishap  two  No.  1  silk  sutures  are  now 
made  to  secure  it  to  the  vesical  mucosa  just  as  it  enters 
the  cavity  of  the  bladder.  These  pick  up  the  ureteral  wall 
on  either  side,  but  do  not  enter  its  lumen.  The  redun- 
dant portion  of  the  ureter  together  with  the  guide  ligature 


OPERATION-WOUNDS 


543 


is  now  cut  off,  leaving  about  \  in.  of   the  tube  projecting 
into  the  bladder  (Fig.  378). 


^ 


Fig.  376. — Threading  the  ureter  into  the  bladder. 


Fig.  377. — Ensheathing  the  ureterovesical  junction 
with  peritoneum. 


544 


GYNAECOLOGICAL  SURGERY 


vi.  Closure  of  the  upper  opening  in  the  bladder. — 
The  upper  opening  in  the  bladder  is  closed  by  tier  sutures 
in  the  manner  described  at  p.  538. 

Difficulties. — The  smallness  of  the  ureter  and  the  diffi- 
culty of  getting  access  to  the  lower  part  of  the  posterior 
wall  of  the  bladder. 

Dangers.  —  (1)  The    junction   may   not   remain    water- 


Fig.  378. — Anchoring  the  ureter  to  the  vesical  mucosa : 
the  redundant  portion  with  the  guide-ligature  has 
been  cut  away. 

tight,  and  (2)  the  implanted  end  of  the  ureter  may  slough. 
The  first  of  these  dangers  is  not  likely  to  arise  if  the  opera- 
tion is  carefully  carried  out.  The  second  danger  is  a  very 
definite  one,  and  is  due  to  the  fact  that  one  channel  of 
blood-supply  to  the  ureter,  namely  the  anastomosis  between 
the  ureteral  and  vesical  vessels,  is  cut  off  by  the  section 
of  the  ureter. 

Uretero -ureteral    anastomosis.  —  Where    the   ureter   is 


OPERATION-WOUNDS    OF   THE   BOWEL     545 

divided  high  up  in  its  course,  i.e.  above  the  pelvis,  it  may 
be  necessary  to  perform  an  anastomosis  of  the  cut  ends. 
There  are  various  methods  of  doing  this,  the  best-known 
being  that  in  which  the  lower  end  is  enlarged  by  splitting 
and  the  upper  end  is  drawn  into  it  by  traction  on  two 
guide-sutures  and  then  fixed  by  other  sutures.  Where 
the  ureter  is  dilated  this  may  be  fairly  easy,  but  in  the 
natural  state  of  the  conduit  it  is  very  difficult  to  perform, 
and  being  performed  is  very  likely  to  result  in  stenosis 
or  complete  blockage.  For  these  reasons  we  think  that 
whenever  it  is  possible  to  pull  down  the  upper  end  suffi- 
ciently to  effect  implantation  into  the  bladder,  this  course 
is  to  be  preferred. 

III.     WOUNDS  OF  THE  BOWEL 

During  an  operation  upon  the  genital  organs  the  bowel 
may  be  injured.  It  may  be  injured  during  the  primary 
incision  when  opening  the  abdominal  cavity  if  sufficient 
care  is  not  taken  when  incising  the  peritoneum  ;  the  rectum 
may  be  incised  when  removing  the  body  of  the  uterus  in 
subtotal  hysterectomy,  and  more  particularly  in  a  total 
hysterectomy,  especially  by  Wertheim's  method,  if  care  is 
not  taken  to  place  a  swab  behind  the  cervix  ;  whilst  various 
parts  of  the  intestine,  and  the  rectum  especially,  may  be 
wounded  during  the  separation  of  adhesions  in  the  opera- 
tion for  pyo-salpinx. 

Wounds  of  the  intestine  are  of  three  degrees  : 
i.  The  peritoneal  coat  only  may  be  injured. 

2.  The  peritoneal  and  muscular  coats  are  divided. 

3.  The  bowel  is  opened. 

The  wound  may  be  clean  cut,  or,  in  the  case  of  the  peri- 
toneum, a  portion  of  this  tissue  of  varying  size  may  be 
torn  off  when  separating  the  bowel  from  some  other  struc- 
ture to  which  it  has  become  adherent. 

Treatment. — 1.  If  only  the  peritoneal  coat  is  injured, 
the  cut  peritoneal  edges  should  be  carefully  sutured  with 
a  continuous  No.  1  silk  on  a  No.  13  needle. 

2J 


546  GYNAECOLOGICAL  SURGERY 

If  a  piece  of  peritoneum  is  torn  off  owing  to  the  separation 
of  a  dense  adhesion,  it  may  be  difficult  to  approximate  the 
torn  edges  of  the  peritoneum  on  account  of  its  thickened 
and  rigid  condition,  due  to  the  adhesion.  In  this  case  it 
will  be  necessary  to  obliterate  the  raw  and  often  badly 
oozing  surface  by  a  series  of  interrupted  silk  sutures. 
These,  on  account  of  the  friable  nature  of  the  tissue,  will 
be  found  readily  to  tear  out,  so  that  great  care  must  be 
taken  in  their  application,  and  it  is  better  to  use  a  some- 
what thicker  silk,  say  No.  2,  as  being  less  liable  to  this 
accident.  Also,  the  suture  must  be  passed  somewhat 
deeper  than  the  peritoneum  to  get  a  good  hold  of  the  tissues. 
It  may  happen  that  the  surface  of  bowel  denuded  of  peri- 
toneum is  so  large  that  if  the  interrupted  sutures  were 
applied  the  lumen  would  be  dangerously  narrowed,  in 
which  case  either  the  raw  surface  must  be  left  uncovered 
or  perhaps  a  piece  of  omentum  can  be  stitched  over  it. 

2.  If  the  muscular  coat  also  is  wounded,  the  cut  edges 
of  the  muscle  must  be  approximated  by  a  continuous 
No.  1  silk  suture,  after  which  the  peritoneal  coat  is  care- 
fully sutured  in  a  similar  manner. 

3.  If  all  three  coats  are  injured  and  the  lumen  of  the 
bowel  is  exposed,  the  muscular  and  mucous  coats  are  sutured 
with  a  continuous  No.  1  silk,  after  which  the  peritoneal 
coat  is  treated  similarly,  and  in  addition  a  few  fine 
Lembert's  sutures  can  be  inserted  in  the  peritoneal  coat 
to  cover  in  the  continuous  suture  already  applied  to  this 
membrane.  If  the  sutures  continually  cut  out,  the  injured 
portion  may  be  fixed  to  the  parietes,  or  resected. 

When  the  muscular  or  muscular  and  mucous  coats 
have  been  wounded,  or  when  there  is  a  raw  surface  left 
on  the  bowel  which  cannot  be  covered  in,  it  is  advisable 
to  insert  a  drainage-tube  down  to  the  wounded  area  so 
that  if  there  is  any  leakage  there  may  be  an  avenue  of 
escape. 


CHAPTER    XXXII 

POSTOPERATIVE    TREATMENT 

i.  Immediate.  i.  The  room.  —  If  the  operation  has 
been  performed  in  a  private  house  or  nursing-home,  the 
room  should  be  properly  ventilated,  the  window  being 
opened  at  the  top  ;  but  care  must  be  taken  that  the  patient 
is  not  in  any  draught,  and,  if  necessary,  screens  must  be 
arranged  to  prevent  this. 

The  temperature  of  the  room  should  be  kept  from 
650  F.  to  700  F. 

The  room  should  be  darkened  by  pulling  down  the 
blinds  or  covering  the  artificial  light  so  that  it  does  not 
shine  directly  on  the  patient's  face,  and  the  house  should 
be  kept  as  quiet  as  possible,  no  one  being  allowed  in  the 
room  whose  presence  is  not  absolutely  necessary.  The 
nurse  will  see  that  the  room  is  tidied  up  and  that  all  un- 
necessary articles  of  furniture  are  removed  before  the 
patient  recovers  from  the  anaesthetic. 

The  nurse  will  require  an  arm-chair  to  sit  in,  a  book 
to  write  her  report  in,  and  a  pen.  She  should  not  leave  the 
room  to  summon  help  or  get  any  article  she  requires,  but 
should  ring  the  bell.  The  fire  in  the  room  can  be  made 
up  without  causing  an  appreciable  noise,  by  having  small 
pieces  of  coal  done  up  in  paper  bags,  or  by  the  nurse  putting 
on  the  coal  with  a  gloved  hand.  There  is  no  necessity 
to  use  the  poker  ;  rattling  with  fire-irons,  etc.,  distresses 
many  patients  exceedingly. 

ii.  Instruments.  —  If  the  surgeon  wishes  the  nurse  to 
clean  his  instruments,  he  should  give  her  proper  directions. 
Instruments  should  be  well  washed  and  scrubbed  with 
lysol  to  remove  the  blood-stains,  all  the  joints  and  ridges 

547 


548  GYNECOLOGICAL  SURGERY 

being  carefully  examined  to  see  that  no  debris  is  adhering 
to  them,  after  which  they  can  be  rinsed  in  clean  water  and 
dried. 

The  flushing  curette  should  have  a  fine  wire  passed 
through  it  (a  long  hat-pin  will  do  very  well),  to  make  sure 
that  no  blood  is  left  behind. 

The  surgeon,  when  he  gets  his  instruments  home,  should 
have  them  polished  with  plate-powder,  scrubbed  with  hot 
water,  and  then  boiled  for  half  an  hour,  after  which  they 
should  be  polished  with  a  dry  clean  cloth.  The  curette, 
after  it  has  been  boiled,  should  have  a  little  absolute 
alcohol  run  through  it,  which  will  dry  it  and  so  prevent 
it  from  rusting. 

iii.  Attention  to  patient. — Immediately  the  patient  is 
returned  to  bed  she  should  be  covered  with  a  hot  blanket, 
and,  if  there  is  much  shock,  hot  bottles  should  be  packed 
round  her,  care  being  taken  that  they  are  efficiently  covered 
with  flannel,  more  especially  the  metal  stoppers,  for,  being 
unconscious,  she  will  be  unable  to  feel  if  she  is  being 
burnt.  Hot-water  bottles  should  always  be  placed  outside 
the  blanket  covering  the  patient,  when  this  accident,  which 
may  very  well  have  disastrous  results,  cannot  occur. 

The  patient's  head  must  be  kept  low  and  on  one  side, 
a  pillow  should  be  placed  under  her  knees,  and,  if  the  opera- 
tion has  been  serious  and  prolonged,  the  recovery  from 
any  shock  present  may  be  assisted  by  tilting  the  foot  of 
the  bed  with  wooden  blocks,  or  books,  about  12  in.  The 
pillow  should  be  replaced  under  her  head  on  recovery 
from  the  anaesthetic.  If  she  commences  to  retch,  the 
nurse,  if  the  operation  has  been  an  abdominal  one,  should 
hold  the  patient's  abdomen  on  both  sides  to  prevent  as 
far  as  possible  any  strain  on  the  stitches.  A  small  porringer 
should  be  adjusted  so  that  it  will  collect  any  ejected  mate- 
rial, and  a  towel  should  be  fastened  round  the  patient's 
neck,  so  that  her  nightgown  and  the  sheets  may  not  be 
soiled. 

After  the  sickness  is  over,  the  mouth  should  be  cleared 


AFTER-TREATMENT  549 

with  glyco-thymoline  or  glycerine  and  borax,  applied  with 
wool  held  in  a  pair  of  forceps. 

It  sometimes  happens  that  patients  are  extremely 
noisy  and  hysterical  when  recovering  from  an  anaesthetic, 
and  on  occasion  it  is  difficult  to  prevent  them  from  throwing 
themselves  out  of  bed.  It  is  more  common  for  patients  to 
act  thus  after  minor  operations,  the  shock  of  a  major 
operation  being  often  so  great  that  the  patient  lies  per- 
fectly quiet.  In  these  very  hysterical  cases  a  severe 
scolding,  accompanied  by  a  gentle  slap  or  two  on  the  face 
with  a  wet  towel,  is  sufficient,  as  a  rule,  to  bring  the  patient 
to  her  senses. 

Surgeons  and  nurses  will,  of  course,  regard  whatever  the 
patient  says  under  the  influence  of  the  anaesthetic  as  sacred, 
not  to  be  mentioned  to  anyone,  even  to  the  patient  herself. 
The  patient,  if  anything  she  has  said  is  repeated  to  her,  will 
not  believe  she  has  been  told  all,  and  will  fear  that  she 
may  have  said  things  that  would  better  have  been  left  un- 
said. Every  doctor  knows  of  cases  in  which  nurses  have 
repeated  to  their  patients  remarks  that  escaped  from 
them  while  unconscious,  and  have  been  surprised  to 
find  that  what  was  intended  to  interest  caused  mental 
distress. 

2.  The  pulse. — The  most  useful  and  most  reliable  guide 
to  the  patient's  condition  after  an  operation  is  the  character 
and  rate  of  her  pulse,  but  as  these  vary  so  much  in  different 
individuals,  even  in  apparent  health,  it  is  most  important 
that  the  pulse  should  have  been  carefully  noted  and  charted 
during  the  days  prior  to  the  operation,  so  that  its  pre- 
operative condition  may  be  taken  into  account  when 
estimating  its  postoperative  characters.  The  pulse  should 
be  taken  every  four  hours  and  charted.  It  is  impossible 
to  overestimate  the  value  of  the  pulse  as  a  guide  to  the 
diagnosis,  prognosis,  and  treatment  of  the  complications 
following  abdomino-pelvic  surgery.  The  aphorism  that  the 
patient  varies  with  the  pulse  is  applicable  to  these  cases 
without    exception.      To    put    it    broadly,    the    pulse-rate 


550  GYNECOLOGICAL  SURGERY 

should  be  highest  during  the  first  twelve  hours  after  opera- 
tion, but  should  not  even  then  much  exceed  ioo. 

After  this,  if  all  is  going  well  the  rate  should  certainly 
have  fallen,  for  a  rising  pulse  after  the  first  twenty-four 
hours  is  of  the  gravest  possible  import.  In  the  larger 
number  of  cases  of  hysterectomy  for  myoma  in  the  Middlesex 
Hospital  and  the  Chelsea  Hospital  for  Women,  the  pulse- 
rate  never  exceeds  80  or  90  at  any  time.  In  estimating  the 
pulse,  the  peculiarities  of  the  patient,  the  nature  and  length 
of  an  operation,  and  the  amount  of  blood  lost  must  always 
be  taken  into  account.  As  an  example,  washing  out  the 
peritoneal  cavity  is  nearly  always  followed  by  a  quick 
pulse  for  a  day  or  two,  while  mental  excitement  in  a 
neurotic  individual  may  cause  an  alarmingly  rapid  heart- 
action.  A  gradually  rising  pulse  combined  with  distension 
of  the  abdomen  and  increasing  fever  makes  it  practically 
certain  that  peritonitis  is  supervening. 

The  pulse-rate  increases  to  140  or  over  with  the  com- 
plications of  shock  or  haemorrhage.  A  quite  temporary 
rise  invariably  occurs  as  the  patient  is  coming  out  of  the 
anaesthetic. 

3.  Respiration.  —  A  rapid  respiration-rate  is  a  most 
ominous  sign  after  abdominal  section.  Occurring  soon 
afterwards  it  points  to  shock  or  haemorrhage,  whilst  its 
presence  later  on  is  associated  with  such  grave  complica- 
tions as  peritonitis,  pneumonia,  and  intestinal  obstruction. 

4.  Temperature. — It  is  just  as  important  to  take  the 
patient's  temperature  as  long  as  possible  before  the  opera- 
tion as  to  take  the  pulse.  This,  therefore,  should  be  done 
twice  daily  and  charted.  After  the  operation  the  tempera- 
ture should  be  charted  every  four  hours.  The  thermo- 
meter— which  should  have  been  properly  tested,  for  cheap 
thermometers  are  unreliable — is  placed  under  the  patient's 
tongue,  and  she  is  told  to  close  her  mouth  and  breathe 
through  her  nose.  A  hot  drink,  for  a  short  time  after  it 
is  taken,  will  raise  the  temperature  locally  in  the  mouth 
as  much  as  a  degree.     Care,  therefore,  must  be  taken  to 


AFTER-TREATMENT  55 1 

choose  a  suitable  time  to  use  the  thermometer.  If  there 
is  any  doubt  as  to  the  correctness  of  the  temperature  when 
taken  in  the  mouth,  the  thermometer  should  be  placed  in 
the  axilla  or  between  the  legs  ;  and  if  there  is  any  suspicion 
that  the  instrument  is  at  fault,  another  should  be  used 
as  a  control.  It  is  an  excellent  rule  on  the  first  visit  after 
an  operation  to  lay  the  back  of  one's  hand  on  the  patient's 
face.  A  warm  face  is  incompatible  either  with  shock  or 
with  haemorrhage  ;  thus  the  presence  of  this  simple  sign 
assures  one  that  these  two  complications,  so  important 
and  so  necessary  to  diagnose  at  once,  are  absent.  In  an 
average  case  the  temperature  rises  pretty  abruptly  to 
99-5°  or  ioo°  F.  within  the  first  six  or  eight  hours.  During 
the  next  twelve  hours  it  frequently  rises  half  a  degree 
higher.  It  then  begins  to  fall,  and  should  reach  the  normal 
in  from  one  to  three  days.  Many  cases,  however,  never 
exceed  99'5°  F.  at  any  time,  whilst  others  maintain  a  tem- 
perature of  990  F.  to  ioo°  F.  for  a  week  without  assignable 
cause  or  obvious  ill-effects.  A  subnormal  temperature  is 
indicative  of  shock  or  haemorrhage.  A  rapidly  rising  tem- 
perature is  bad  at  any  time,  but  it  is  especially  so  on  the 
second  or  third  day,  when  peritonitis  may  be  feared  as  a 
likely  cause.  A  persistently  high  temperature  after  opera- 
tion, without  anything  obvious  to  account  for  it,  should 
always  lead  to  an  examination  of  the  abdominal  wound  for 
stitch-abscess  and  of  the  pelvis  for  hematocele.  Fever 
occurring  in  the  second  week  is  often  due  to  an  inflamma- 
tory effusion  around  a  ligature,  or  is  the  herald  of  femoral 
thrombosis.  Violent  nervous  disturbance  may  lead  to  a 
very  marked  and  sudden  elevation  of  temperature,  which, 
however,  is  not  maintained.  It  is  accompanied  by  a  full 
though  rapid  pulse,  and  there  is  an  absence  of  local  ab- 
dominal and  pelvic  signs.  These  points  will  allay  anxiety. 
Ether-bronchitis  will  maintain  fever  for  some  days. 

5.  Tongue.  —  The  tongue,  after  the  first  twenty-four 
hours,  in  abdominal  section  should  be  moist.  It  is  generally 
whitish  in  colour  so  long  as  the  patient  is  not  taking  solid 


552  GYNAECOLOGICAL  SURGERY 

food.  In  such  grave  conditions  as  peritonitis  and  intes- 
tinal obstruction  it  is  dry,  brown,  and  cracked,  or  glazed, 
red,  and  ulcerated ;  such  appearances  are  of  very  bad 
prognosis. 

The  greatest  pains  should  be  taken  with  the  mouth 
after  all  cases  of  abdominal  section,  as  indicated  at  p.  568. 
Glyco-thymoline  and  listerine  both  make  admirable  mouth- 
washes. 

6.  Thirst. — One  of  the  bitterest  complaints  of  a  patient 
during  the  twenty-four  hours  succeeding  a  severe  opera- 
tion is  of  thirst.  The  best  way  to  relieve  this  is  to  inject 
6  ounces  of  saline  solution  (a  teaspoonful  of  chloride  of 
sodium  to  a  pint  of  water)  into  the  rectum  every  four 
hours.  Other  remedies  consist  in  rinsing  the  mouth  out 
with  warm  water,  or  with  a  weak  solution  of  Condy's  fluid. 
Ice  should  not  be  given  ;  it  causes  flatulence,  and  only 
relieves  thirst  until  it  has  melted. 

7.  The  bladder,  (a)  Minor  operations. — After  most  of 
the  minor  operations  described  in  this  book  there  is  no 
necessity  to  use  the  catheter,  unless  there  be  retention  of 
urine. 

But  in  excision  of  the  vulva  and  such  cases,  where 
urine  passing  over  the  surfaces  would  be  a  disadvantage, 
the  catheter  may  be  used  for  the  first  few  days,  though 
it  is  not  our  practice  to  do  so.  Where  it  has  been  necessary 
to  pack  the  vagina  tightly  the  catheter  will  have  to  be 
used.  Many  patients  after  perineoplasty  are  unable  to 
pass  urine,  and  the  catheter  will  have  to  be  used  for  some 
days.  In  operations  involving  the  bladder  it  is  advisable 
to  catheterize  the  patient  for  some  little  time  (see  p.  147). 

(b)  Major  operations. — In  vaginal  hysterectomy  and 
abdominal  section  the  catheter  is  passed  six  hours  after 
the  operation,  and  unless  the  patient  is  troubled  with 
retention  its  further  use  is  not  indicated.  It  is  passed 
in  order  to  estimate  the  quality  and  character  of  the  urine. 
Exceptions  to  this  rule  must,  however,  be  made  when 
pressure-forceps  have  been  left  on  to  stop  haemorrhage  in 


AFTER-TREATMENT  553 

vaginal  hysterectomy,  in  which  case  the  urine  must  be 
drawn  off  every  eight  hours  until  they  are  removed,  and 
during  the  manipulations  necessary  for  this  object  the 
greatest  care  must  be  taken  not  to  disturb  the  forceps. 

Likewise,  after  hysterectomy  the  catheter  may  be  used 
for  twenty-four  hours  to  prevent  traction  on  the  stump 
by  distension  of  the  bladder.  In  the  radical  operation  for 
carcinoma  of  the  cervix,  the  urine  should  be  regularly 
drawn  off  for  several  days,  as  there  is  practically  in  all 
cases  an  ounce  or  two  of  residual  urine,  due  to  bruising, 
injury,  or  altered  relations  of  the  bladder.  The  amount 
of  urine  passed  each  time  should  be  carefully  measured, 
and  any  abnormality  in  its  appearance,  such  as  the  presence 
of  blood,  noted.  The  quantity  first  passed  or  drawn  off 
after  operation  amounts,  as  a  rule,  to  4  to  7  ounces,  but  in 
very  severe  cases,  especially  the  radical  procedures  above 
referred  to,  no  urine  is  secreted  at  all  for  several  hours, 
and  then  only  in  small  quantities.  If  the  quantity  is  less 
than  4  ounces,  one  naturally  thinks  of  shock,  haemorrhage, 
suppression,  or  injury  to  the  ureter.  In  the  case  last 
mentioned  the  urine  may  be  mixed  with  blood,  but  it  is 
not  necessarily  so. 

Catheterization. — By  the  careless  use  of  the  catheter  a 
patient  may  sustain  damage,  due  to  the  introduction  of 
micro-organisms  into  her  bladder,  which  will  cause  many 
weeks  of  misery,  even  if  it  is  not  the  immediate  cause  of 
her  death,  for  the  cystitis  thus  set  up  may  spread  by  way 
of  the  ureters  to  both  kidneys  and  kill  the  patient,  or  to 
one  kidney,  which  may  become  so  disorganized  that  nothing 
short  of  its  removal  will  save  her. 

The  nurse,  therefore,  has  to  remember  three  important 
and  absolute  rules  when  using  a  catheter :  (1)  to  make  her 
hands  as  aseptic  as  she  possibly  can ;  (2)  to  sterilize  the 
catheter ;  and  (3)  to  swab  the  vulva,  more  especially  that 
part  where  the  orifice  of  the  urethra  is  situated,  with  a 
solution  of  biniodide  of  mercury,  1 — 1,000. 

A  glass  catheter  should  always  be  used,  except  when 


554  GYNECOLOGICAL  SURGERY 

the  instrument  has  to  be  left  in,  in  which  case  a  soft  rubber 
catheter  is  indicated. 

Before  its  use,  and  afterwards,  the  catheter  should  be 
boiled,  and  when  not  in  use  it  must  be  kept  in  a  solution 
of  carbolic  acid,  I — 20. 

Catheters  are  cleaned  after  use  by  holding  them  under 
a  tap  and  allowing  a  stream  of  water  to  run  through  them, 
or  by  driving  water  through  them  with  a  syringe ;  and  in 
addition,  as  the  soft  rubber  catheter  has  an  eye,  attention 
must  be  particularly  directed  towards  the  cleansing  of  this 
part. 

Having  thoroughly  washed  and  scrubbed  her  hands 
with  soap  and  water,  the  nurse  dips  them  for  a  few  minutes 
in  a  solution  of  biniodide  of  mercury,  1 — 1,000,  after  which 
she  proceeds  to  clean  the  patient's  vulva.  The  patient  lies 
on  her  back  with  her  legs  drawn  up  and  separated,  and 
the  nurse  then  separates  the  labia  with  the  first  and  second 
fingers  of  the  left  hand,  her  wrist  resting  meanwhile  on  the 
pubes  of  the  patient.  The  vestibule  now  comes  into  view, 
and  is  freely  swabbed  with  a  solution  of  biniodide  of 
mercury,  1 — 1,000,  which  will  effectually  get  rid  of  any 
•septic  matter  in  this  neighbourhood,  and  so  prevent  its 
introduction  into  the  bladder  by  the  catheter.  The  catheter 
should,  of  course,  be  passed  by  sight.  A  porringer  having 
been  placed  between  the  patient's  legs  for  the  urine  to 
run  into,  the  catheter  should  be  held  in  the  right  hand 
and  gently  passed  along  the  urethra  until  the  escape  of 
urine  denotes  that  it  has  entered  the  bladder.  With  the 
labia  still  separated,  the  catheter  is  held  in  position,  and 
somewhat  depressed,  until  the  stream  of  urine  becomes 
smaller  and  almost  stops,  when  the  instrument  should  be 
withdrawn  for  a  short  distance  and,  as  a  rule,  the  stream 
of  urine  will  be  augmented,  after  which  it  will  gradually 
decrease  until  it  stops,  which  is  the  signal  that  the  bladder 
is  empty.  On  withdrawal  of  the  catheter,  the  thumb 
should  be  kept  over  its  external  orifice  to  prevent  the 
urine  that  remains  in  it  from  being  spilt  on  the  patient  or 


AFTER-TREATMENT  555 

bedclothes.  An  inexperienced  nurse  may  have  some  diffi- 
culty in  identifying  the  urethral  orifice,  and  as  a  consequence 
may  pass  the  catheter  into  the  vagina.  Should  this  happen, 
the  catheter  must  be  re-sterilized  before  any  further  attempt 
is  made  to  pass  it.  Some  nurses  make  sure  of  avoiding  this 
mistake  by  putting  a  swab  of  absorbent  wool  in  the  vaginal 
orifice  before  passing  the  catheter.  A  real  difficulty  may 
present  itself  when  a  tumour  is  pressing  against  the  neck 
of  the  bladder  or  urethra,  in  which  case  the  surgeon  will 
have  to  pass  the  catheter.  If  the  case  should  be  a  septic 
one  a  special  catheter  must  be  kept  for  it,  and  this,  if 
made  of  india-rubber,  should  be  destroyed  when  not  further 
needed. 

9.  The  bowels,  (a)  Minor  operations. — On  the  second 
night  after  most  minor  operations  the  patient  is  given 
an  aperient,  and  the  following  morning  an  enema,  if  neces- 
sary, after  which  the  bowels  are  kept  acting  regularly. 
The  exact  form  of  aperient  is  not  a  matter  of  much  import- 
ance, and  the  patient,  may  be  ordered  any  drug  she  is  in 
the  habit  of  taking. 

When  the  operation  has  been  of  a  plastic  nature  in  the 
neighbourhood  of  the  rectum,  such  as  a  perineoplasty,  pos- 
terior colporrhaphy,  or  recto-vaginal  fistula,  the  manage- 
ment of  the  bowels  is  a  matter  of  great  importance,  since 
distension  of  the  rectum  may  tend  to  prevent  union,  and 
faecal  contamination  may  produce  sepsis.  On  account  of 
these  drawbacks,  some  surgeons  prefer  to  keep  the  bowels 
of  the  patient  confined  for  four  days  until  union  is  firm 
and  granulations  have  formed  which  will  prevent  infection. 
The  chief  objection  to  this  method  of  treatment  is  that 
scybala  passed  at  the  end  of  this  period  may  by  their  size 
cause  the  wound  to  break  down,  although  this  can  gener- 
ally be  prevented  by  injecting  4  ounces  of  warm  olive  oil 
into  the  rectum  two  hours  before  the  soap-and-water  enema 
is  administered.  Another  method  in  these  cases  is  to  keep 
the  bowels  acting  by  drugs  from  the  first,  and  direct  the 
nurse  to  use  scrupulous  care  in  keeping  the  parts  as  clean 


556 


GYNECOLOGICAL  SURGERY 


as  possible.     Of  the  two  methods  we  prefer  the  first.    If  drugs 
are  being  used  the  following  prescription  will  suffice  : — 

$)      Mag.  carb.  lev.  gr.  x. 
Mag.  sulph.  3i- 
Aq.  menth.  pip.  ad  §i. 

This  should  be  given  at  2  a.m.  the  following  day 
and  repeated  every  four  hours  until  the  bowels  are  opened, 
and  then  as  often  as  is  necessary  to  secure  an  action. 

Another  admirable  aperient  in  gynaecological  cases  is 
the  following  : — 

Ijc      Ext.  cascar.  liq.  3i- 
Mag.  sulph.  3i- 
Tr.  hyoscyami  3ss. 
Aq.  menth.  pip.  ad  §i. 

Dose,  from  two  teaspoonfuls  to  two  tablespoonfuls. 

(b)  Major  operations. — In  abdominal  section  and  vaginal 
hysterectomy  an  enema  of  olive  oil,  4  ounces,  is  adminis- 
tered at  4  a.m.  on  the  fourth 
day  following  the  operation, 
and  three  hours  later  a  pint 
of  soap-and-water  is  injected, 
after  which  the  bowels  are 
kept  acting  once  daily  by  suit- 
able aperients. 

Rectal  tube.  — ■  The  rectal 
tube  (Fig.  379)  is  first  passed 
twelve  hours  after  the  operation,  and  it  should  then  be  used 
every  four  hours  as  long  as  may  be  necessary.  If  saline  injec- 
tions are  being  administered,  it  should  be  passed  prior  to 
their  introduction.  In  passing  the  rectal  tube  great  care 
must  be  taken  to  see  that  it  does  not  become  kinked,  as  this 
will  necessitate  its  being  withdrawn  and  again  introduced. 
The  distance  the  nurse  will  be  able  to  pass  the  tube  varies 
in  different  patients,  but  at  any  rate,  whilst  using  every 
care,  it  must  be  pushed  in  as  far  as  it  will  go,  and  on  an 
average  a  tube  of  31  in.,  which  is  the  correct  length,  will 


Fig.  379.— Rectal  tube. 


AFTER-TREATMENT  557 

pass  21  in.  Some  rectal  tubes  are  made  with  a  hole  in  the 
side  of  that  portion  which  goes  into  the  rectum,  and  in 
others  the  hole  is  at  the  end ;  the  latter  is  the  better 
pattern. 

If  the  end  is  well  smeared  with  vaseline  very  little 
discomfort  will  be  caused  by  passing  the  tube,  while  the 
relief  to  the  patient  is  often  very  marked.  If  the  patient 
suffers  from  haemorrhoids,  the  passage  of  the  tube  may 
cause  great  pain,  which  can  be  obviated  in  some  degree 
by  introducing  into  the  rectum  a  cocaine  suppository 
shortly  before.  The  tube  is  left  in  position  as  long  as  any 
flatus  passes  ;  in  the  absence  of  flatus  it  should  be  left 
in  situ  from  five  to  ten  minutes.  The  flatus  should  be 
made  to  pass  into  fluid  by  holding  the  free  end  of  the 
tube  under  boric  acid  or  mercury  solution  contained  in 
a   porringer. 

As  a  rule  very  little,  if  any,  flatus  passes  by  the  tube 
for  the  first  twenty-four  hours,  but  if  its  expulsion  is  delayed 
much  longer  than  this  the  patient  will  commence  to  experi- 
ence some  discomfort,  in  which  case  a  rectal  wash-out  or 
an  enema  of  rue  or  turpentine  is  indicated  and  usually 
affords  great  relief.  The  methods  of  administration  are 
described  on  pp.  587-88. 

10.  Diet,  (a)  Minor  operations. — Six  hours  after  most 
minor  operations  the  patient  is  given  4  ounces  of  tea  and 
milk,  or  of  hot  milk-and-water,  and  then,  as  soon  as  she  is 
able  to  take  it,  ordinary  diet  is  allowed. 

(b)  Major  operations. — The  patient  has  to  be  fed  most 
carefully,  and  a  note  of  all  she  takes  is  entered  in  a 
special  book  by  the  nurse,  the  total  quantities  being 
added  up  every  twelve  hours  so  that  the  surgeon  may 
see  how  much  the  patient  is  taking.  It  is  useful  in 
feeble  patients  to  add  half  an  ounce  of  brandy  to  the 
routine  rectal  saline  injections  during  the  first  twenty-four 
hours.  The  following  tables  form  a  guide  as  to  how  the 
patient  should  be  treated,  supposing  she  is  progressing 
normally  : — 


558 


GYNECOLOGICAL  SURGERY 


NURSING   CHART   USED    BY   THE   AUTHORS    FOR 
ALL    CASES    OF    ABDOMINAL    SECTION 


First  Day 


6 

a.m. 

8 

a.m. 

9 

a.m. 

IO 

a.m. 

I 

30  p.m. 

I. 

45  p.m 

2  p.m., 
Operation 

6  p.m. 


10  p.m. 


12  midnt. 

1  a.m. 

2  a.m. 


Directions 


Simple  enema  Oi 


Fresh 


resh  compress  of  1 — 4,000  perchloride 
of  mercury  applied 


Douche  of  perchloride  of  mercury,  1 — 

4,000 
Catheter.    Injection    of    liquor    strych- 

ninae  7t]iii 

Put  patient  to  bed,  covered  with  a  blan- 
ket, head  low,  pillow  under  knees,  and 
packed  with  hot-water  bottles  well 
protected  ;  cradle  to  keep  off  weight 
of  clothes 

When  patient  recovers  consciousness, 
if  she  is  sick  or  retching  the  abdo- 
men should  be  held  at  both  sides  of 
wound  to  protect  stitches 

Take  pulse,  respiration,  and  tempera- 
ture. Saline  solution  §vi  per  rectum. 
Liquor  strychninse  TT|iii 

First  Night 

Take  pulse,  respiration,  and  temperature 
Inject  liquor  strychninas  Tl\iii.  Pass 
catheter  (measure  the  urine).  Pass 
rectal  tube  and  afterwards  inject  per 
rectum  warm  saline  solution  §vi. 
Patient  may  have  a  pillow.  See  that 
water  bottles  are  hot  and  protected 


Pulse,  respiration,  and  temperature. 
Pass  rectal  tube  and  then  inject  warm 
saline  solution  §vi  per  rectum 


Nourishment 


Tea  §iv,  milk 
§ii,  two  slices 
bread  &  butter 


Beef  tea  or 
chicken  broth 


Hot  water 


3i 
3i 

3i 


AFTER-TREATMENT 

First  Night  {continued) 


559 


i  3  a.m. 


4  a.m. 

5  a.m. 

6  a.m. 


7   a.m. 


s  a.m. 

9  a.m. 

io  a.m. 


ii   a.m. 
12  noon 


p.m. 


3  P-m. 


Directions 


If  patient  is  very  collapsed,  surgeon 
may  order  brandy  §ss,  beef -tea  §iii 
per  rectum 


Pulse,  respiration,  and  temperature. 
Rectal  tube.  Saline  solution  §vi  per 
rectum.  Injection  liquor  strychnine 
TT|ni 

Brush,  comb,  and  plait  hair.  Wash 
patient's  hands  and  face,  shoulders, 
lower  part  of  back,  after  which  rub 
eau-de-Cologne  and  boric  powder 
into  the  shoulders  and  back. 
Cleanse  mouth.  Change  draw-sheet 
and  top  sheet.  Add  up  amount  of 
nourishment,  sleep,  and  urine  passed 
during  the  night,  and  enter  in  report 
book 

If  patient  is  able  to  pass  her  urine 
naturally  and  of  sufficient  quantity, 
omit  the  catheter  in  the  following 
directions.  If,  however,  when  patient 
passes  urine  naturally  it  is  of  small 
amount,  the  catheter  must  be  passed 
immediately  after  the  urine  is  evac- 
uated in  order  to  ascertain  if  the 
bladder  empties  itself,  and  if  it  does 
not,  the  catheter  must  be  continued 
as  below 

Second  Day 


Pulse,  respiration,  and  temperature. 
Strychnine  n\hi.  Rectal  tube.  Saline 
solution  §vi  per  rectum.  Cleanse 
mouth 


Pulse,  respiration,  temperature, 
hands  and  face.  Rectal 
Catheter.  Saline  solution  | 
rectum.     Mouth  cleansed 


Wash 
tube. 
per 


VI 


Nourishment 


Hot  water  3* 


3i 
3i 


§i 


Hot  water 


3] 

51 


Tea,   §i,   milk 

§i 
Milk  3  iv,  lime- 
water  3  ii,  hot 
water  3'-i 


56o  GYNAECOLOGICAL  SURGERY 

Second  Day  {continued) 


4  p.m. 


5  P-m. 

6  p.m. 


7  p.m. 


8  p.m. 

9  p.m. 
io  p.m. 


ii  p.m. 
12  midnt. 


2  a.m. 


3  a.m. 

4  a.m. 

5  a.m. 

6  a.m. 


7   a.m. 


Directions 


Pulse,  respiration,  temperature.  Injec- 
tion liquor  strychnine  H|iii.  Rectal 
tube.     Saline  solution  §x  per  rectum 

Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet. 
Add  up  amount  of  nourishment, 
sleep,  and  urine  passed  during  the 
day,   and  enter  in  report  book 


Second  Night 


Pulse,  respiration,  temperature.  Rectal 
tube.  Catheter.  Saline  solution  §x 
per  rectum.     Mouth  cleansed 


Pulse,  respiration,  temperature.  Injec- 
tion liquor  strychninae  H\iii.  Rectal 
tube.  Saline  solution  §vi  per  rectum. 
Mouth  cleansed 


Pulse,  respiration,  temperature.    Rectal 

tube.     Catheter  if  necessary.     Saline 

solution  §vi  per  rectum 
Brush,    comb    and    plait   hair.      Wash 

patient  as  before.     Mouth  cleansed. 

Change   draw-sheet    and    top   sheet. 

Add    up    amount    of     nourishment, 

sleep,  and  urine  passed  during  night, 

and  enter  in  report  book 


Nourishment 


Milk3iv,  lime- 
water  3  ii,  hot 
water  3ii 
Hot  water  3  ii 
Milk  3  iv,  lime- 
water  3  ii,  hot 
water  3h 


Milk  3  iv,  lime- 
water  3  h\  hot 
water  3h 

Milk  §i,  lime- 
water  3  ii,  hot 
water  3n' 

Hot  water  §ii 


Milk  §i,  lime- 
water  3  ii,  hot 
water  3ii 


Tea  gii,  milk 
3>i 


8   a.m. 


9 

a.m. 

IO 

a.m. 

ii 

a.m. 

12 

noon 

2  p.m. 

3  P-m- 

4  p.m. 

6  p.m. 

7  p.m. 


8  p.m. 


9  p.m. 
io  p.m. 

12  midnt. 


AFTER-TREATMENT 

Third  Day 


56i 


Directions 


Pulse,  respiration,  temperature.  Rectal 
tube.  Mouth  cleansed.  Omit  saline 
injections 


Pulse,  respiration,  temperature.  Wash 
hands  and  face.  Rectal  tube.  Mouth 
cleansed 


Pulse,  respiration,  temperature 


Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet. 
Add  up  amount  of  nourishment, 
sleep,  and  urine  passed  during  the 
day,  and  enter  in  report  book 

Third  Night 


Pulse,  respiration,  temperature, 
tube.     Mouth  cleansed 


Rectal 


Pulse,  respiration,  temperature.  Rectal- 
tube.     Mouth  cleansed 


Nourishment 


Milk  §  iiss, 
lime-water 
3  ii,  hot  water 

3ii 


Tea  §ii,  milk 
§ii 

Milk  §  iiss, 
lime-water 
3ii,  water  3h 


Millagiii,  lime- 
water  3ii, 
water  3U' 

Barley  -  water 
giii 

Milkg  hi,  lime- 
water  3ii, 
water  3U 

Barley  -  water 
§iii 

Milk  §  hi,  lime- 
water  3h, 
water  3h 


2K 


562  GYNAECOLOGICAL  SURGERY 

Third  Night  (continued) 


Directions 

Nourishment 

6 

a.m. 

Pulse,  respiration,  temperature 

Tea  §ii,  milk 
§ii 

7 

a.m. 

Brush,    comb   and   plait  hair.       Wash 
patient  as  before.     Mouth  cleansed. 
Change    draw-sheet    and    top    sheet. 
Add    up    amount    of    nourishment, 
sleep,  and  urine  passed,  and  enter  in 
report  book 

Fourth  Day 

8 

a.m. 

Milk  §iv,  lime- 
water  3h, 
water  3h 

9 

a.m. 

Oil  and  soap  enema 

10 

a.m. 

Pulse,  respiration,  temperature.    Mouth 
cleansed.     Omit  rectal  tube 

„ 

12  noon 

Chicken-broth 

§iv  and  jun- 

ket or  boiled 

custard 

2 

p.m. 

Pulse,  respiration,  temperature.     Wash 

Milk  §iv,  soda- 

hands  and  face 

water  §ii 

4 

p.m. 

Tea  gii,  milk 
§ii,  one  slice 
of  bread  and 
butter,  no 
crust 

6 

p.m. 

Pulse,  respiration,  temperature.     Injec- 

Chicken-broth 

tion  liquor  strychninas  Tl\iii 

or  beef-tea 
and  toast  giv 

7 

p.m. 

Brush,    comb,    and   plait   hair.    Wash 
patient  as  before.     Mouth  cleansed. 
Change    draw  -  sheet    and    top    and 
bottom   sheet.     Add    up    amount  of 
nourishment,  sleep,  and  urine  passed 
during  the  day,  and  enter  in  report 
book 

Fourth  Night 

8 

p.m. 

Mild  aperient  given 

Milk  §  iv,  soda- 
water  §  ii 

io 

p.m. 

Pulse,  respiration,  temperature.   Mouth 
cleansed 

Egg  and  milk 

12 

midnt. 

Barley  -  water 
^iv 

AFTER-TREATMENT 

Fourth  Night  {continued) 


563 


4  a.m. 

6  a.m. 

7  a.m. 


10 

a.m. 

12 

noon 

2 

p.m. 

4 

p.m. 

6 

p.m. 

7 

p.m. 

8  p.m. 


10  p.m. 


Directions 


Pulse,  respiration,  temperature 


Pulse,  respiration,  temperature 
Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  and 
bottom  sheets.  Add  up  amount  of 
nourishment,  sleep,  and  urine  passed 
during  the  night,  and  enter  in  report 
book 

Fifth  Day 


Pulse,  respiration,  temperature 


Wash  hands  and  face 


Pulse,  respiration, temperature 

Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet. 
Add  up  amount  of  nourishment, 
sleep,  and  urine  passed  during  the 
day,  and  enter  in  report  book 

Fifth  Night 


Pulse,  respiration,   temperature 


Nourishment 


Milkgiv,  soda- 
water  5ii 


Tea  §iv&  milk 
§ii,  or  coffee 
giii  and  milk 
giii,  steamed 
egg,  two 
slices  of  bread 
and  butter 

Chicken-broth 
or  beef-tea  & 
toast  §iv 

Fish  and  light 
pudding 

Tea  §iv,  milk 
§  ii,  bread 
and  butter 

Milk  gvi 


Chicken-broth 
or  beef-tea 
and  toast  §  iv 

Milk  5  vi,  water 


564  GYNECOLOGICAL  SURGERY 

Fifth  Night   (continued) 


12 

midnt. 

2 

a.m. 

6 

a.m. 

7 

a.m. 

8  a.m. 


IO 

a.m. 

12 

noon 

2 

p.m. 

4 

p.m. 

6 

p.m. 

7 

p.m. 

8  p.m. 

io  p.m. 
7   a.m. 


Directions 


Pulse,  respiration,  temperature 
Pulse,  respiration,  temperature 
Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet. 
Add  up  amount  of  nourishment, 
sleep,  and  urine  passed  during  the 
night,  and  enter  in  report  book 


Sixth  Day 

Pulse,  respiration,  temperature 


Wash  hands  and  face 


Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet 


Sixth  Night 

Pulse,   temperature,  respiration 


Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change   draw-sheet  and  top  sheet 


Nourishment 


Barley  -  water 


Tea  §iv,  milk 
§ii,  or  coffee 
|  hi  and  milk 
giii 

Chicken-broth 
or  beef-tea 
§iv  and  one 
slice  toast 

Chicken  and 
lightpudding 

Tea  §iv,  milk 
§ii,  two  slices 
bread  and 
butter 

Milk  5vi 


Chicken-broth 
or  beef-tea 
§iv  and  one 
slice  toast 

Milkgvi,  water 
^ii 


AFTER-TREATMENT 

Seventh  Day 


565 


8  a.m. 


10 

a.m. 

12 

noon 

2 

p.m. 

4 

p.m. 

2 

p.m. 

7 

p.m. 

8   p.m. 

10  p.m. 
7  a.m. 


Directions 


Pulse,   respiration,   temperature 


Nourishment 


Wash  hands  and  face 


Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  and 
bottom  sheets 

Seventh  Night 

Pulse,   respiration,  temperature 


Brush,  comb,  and  plait  hair.  Wash 
patient  as  before.  Mouth  cleansed. 
Change  draw-sheet  and  top  sheet 

Fifteenth  Day 

Patient  is  lifted  on  to  couch 

Twenty-first  Day 

Patient  goes  home 


Tea  §iv,  milk 
§ii,  or  coffee 
§iii  and  milk 
giii 

Chicken-broth 
or  beef  -  tea 
§iv  and  one 
slice  toast 

Mutton  and 
light  pudding 

Tea  §iv,  milk 
§ii,  two  slices 
bread  and 
butter 

Milk  ?vi 


Chicken-broth 
or  beef-tea 
giv  and  one 
slice  toast 

Milkgvi,  water 


11.  Dressing,  (a)  Minor  operations.  —  The  greatest 
difficulty  is  experienced  after  perineoplasty  in  keeping  the 
wound  aseptic  owing  to  its  situation,  since  it  is  liable  to 
become  contaminated  with  fseces,  urine,  the  menstrual  flow, 


566  GYNAECOLOGICAL  SURGERY 

or  vaginal  discharge,  and  nearly  all  the  failures  of  this 
operation  are  due  to  the  wound  becoming  septic.  For- 
tunately, even  when  this  occurs,  although  the  convalescence 
is  delayed  and  the  pain  and  discomfort  to  the  patient  are 
enhanced,  a  fair  result  is  generally  obtained,  the  wound 
healing  by  granulation.  Occasionally  it  sloughs  and  totally 
breaks  down,  and  after  a  long  illness  the  patient  finds  to 
her  chagrin  that  she  is  no  better  and  that  the  operation 
will  have  to  be  repeated. 

Since  the  result  depends  so  much  on  the  care  of  the 
wound,  this,  whenever  soiled,  should  be  dressed  by  douching 
it  with  a  solution  of  biniodide  of  mercury,  i — 2,000.  A 
vaginal  douche  of  boric  acid  should  be  given  twice  a  day. 
Mercury  should  not  be  used,  as  there  is  danger  of  some  of 
the  solution  remaining  in  the  vagina  in  consequence  of  the 
narrowing  of  the  orifice  produced  by  the  perineoplasty.  The 
legs  should  be  tied  together  for  the  first  forty-eight  hours. 
The  stitches  should  be  removed  from  the  seventh  to  the 
tenth  day  unless  the  tension  on  them  is  too  great  or  they 
have  cut  through,  when  they  should  be  taken  out  earlier. 

Colporrhaphy. — A  vaginal  douche  of  boric  acid  is  given 
twice  a  day,  and  otherwise  the  wound  is  treated  in  a  similar 
manner  to  that  described  for  perineoplasty. 

Curetting. — The  tampons  are  removed  the  morning  after 
the  curetting,  and  then  a  vaginal  douche  consisting  of  a 
quart  of  a  solution  of  biniodide  of  mercury,  1 — 4,000,  is 
given,  and  repeated  night  and  morning. 

If  the  uterus  has  been  packed  with  gauze,  this  should 
be  removed  in  twenty-four  hours  according  to  the  directions 
given,  and  its  withdrawal  must  be  carried  out  very  gently 
to  minimize  the  pain  and  ensure  that  the  gauze  is  not 
broken  off  short,  with  the  result  that  a  piece  is  left  in  the 
uterus. 

Vulval  operations. — The  parts  should  be  kept  scrupulously 
clean  by  changing  the  dressings  whenever  they  are  soiled 
and  douching  the  parts  with  mercurial  solution,  1 — 2,000. 
The  stitches  should  be  taken  out  on  the  eighth  day. 


AFTER-TREATMENT  567 

Operations  on  the  vagina. — If  gauze  has  been  left  in  the 
vagina  it  is  removed  the  morning  following  the  operation, 
after  which  the  vagina  is  douched  twice  daily  with  mercurial 
solution,  1 — -4,000. 

Cervical  operations  are  treated  in  a  similar  way. 

(b)  Major  operations. — After  vaginal  hysterectomy  the 
gauze  is  removed  in  thirty-six  hours,  and  then  the  lower 
part  of  the  vagina  should  be  swabbed  with  pellets  of 
wool  held  with  forceps  and  moistened  in  a  solution  of 
mercury,  1 — 2,000,  twice  daily  for  some  days. 

If,  because  of  haemorrhage,  forceps  have  been  left  on, 
they  may  be  disturbed  by  the  patient  while  she  is  recovering 
from  the  anaesthetic,  and  the  nurse  must  take  particular 
care  to  prevent  this.  There  is  also  some  danger  of  the 
nurse  detaching  the  forceps  when  attending  to  the  patient, 
unless  she  uses  great  care. 

The  injured  parts  sometimes  slough  and  the  ligatures 
commence  to  separate,  usually  about  the  tenth  day,  with 
the  result  that  there  may  be  a  most  offensive  vaginal 
discharge,  and  in  this  case  a  vaginal  douche  of  iodine 
solution,  5i — Oi,  will  be  indicated,  but  in  no  circum- 
stances should  a  douche  be  given  until  a  week  after  the 
operation. 

The  douche  must  be  given  with  very  little  pressure, 
the  can  being  held  only  just  a  little  higher  than  the  bed. 

Abdominal  section. — The  stitches  are  taken  out  on  the 
seventh  day,  and  the  wound  is  then  re-dressed.  If  Michel's 
clips  are  used,  these  should  be  taken  out  on  the  fourth  day. 
When  a  drain  has  been  left  in,  the  dressings  will  have  to  be 
changed  as  often  as  they  are  soiled.  If  gauze  has  been 
inserted  to  check  haemorrhage,  it  is  removed  in  twenty- 
four  hours,  and  the  hole  may  then  be  closed  by  an  inter- 
rupted stitch  that  has  been  purposely  left  untied  at  the 
operation.  If  a  drain  has  been  used  because  pus  has  soiled 
the  peritoneal  cavity,  or  because  the  bowel  has  been  injured, 
it  should  be  left  in  situ  for  forty-eight  hours.  After  this 
it  should  be   removed  and  cleansed  daily,   being  allowed 


568  GYNECOLOGICAL  SURGERY 

to  remain  in  as  long  as  there  is  much  discharge  ;  it  should 
be  slightly  shortened  every  day.  Further  information  on 
the  management  of  drainage-tubes  will  be  found  on  p.  46. 

12.  Position  of  the  patient  in  bed.  (a)  Minor  opera- 
tions.— In  most  of  the  minor  operations  the  position 
assumed  by  the  patient  in  bed  is  of  no  particular  import, 
After  perineoplasty,  owing  to  the  local  swelling  and  tender- 
ness the  patient  will  be  more  comfortable  on  her  side. 

(b)  Major  operations. — As  soon  as  the  shock  of  the 
operation  has  passed  off,  the  patient  may  be  allowed  to 
turn  on  to  her  side,  being  kept  in  that  position  by  pillows 
placed  under  her  shoulder  and  hip.  In  twenty-four  hours 
or  less  her  shoulders  should  be  well  raised  on  pillows  and 
she  should  be  nursed  in  the  semi-reclined  posture.  This  has 
the  great  advantage  that  it  encourages  the  gravitation  of 
peritoneal  fluid  into  the  pelvis  and  minimizes  any  risk  of 
general  peritonitis.  The  patient  may  be  allowed  to  sit  up 
in  bed  of  herself  on  the  thirteenth  day. 

Exceptions. — If  the  patient  is  very  anaemic  from  haemor- 
rhage before  or  during  the  operation,  the  above  directions 
must  be  somewhat  modified.  She  must  be  kept  as  quiet 
as  possible  for  a  longer  period  and  must  not  be  allowed  to 
exert  herself  in  any  way,  as  the  danger  of  a  sudden  syncope 
is  always  present  for  some  days.  Again,  if  she  is  elderly, 
or  is  subject  to  bronchitis,  or  if  bronchitis  or  broncho- 
pneumonia supervenes  on  the  anaesthetic,  she  must  be 
propped  up  on  pillows  as  soon  as  possible ;  and  the  same 
practice  must  be  pursued  in  cases  of  sepsis  when  drainage 
is  being  employed. 

The  best  apparatus  for  maintaining  a  patient  in  the 
sitting  posture  is  a  bolster  placed  across  the  bed  immediately 
below  her  buttocks.  The  bolster  is  kept  in  position  by 
means  of  two  pieces  of  bandage,  one  end  of  each  being 
sewn  to  the  end  of  the  bolster,  and  the  other  tied  to  the 
bedposts  at  the  head-end  of  the  bed. 

13.  Toilet  of  patient.  Mouth. — Every  four  hours  until 
the  patient  is  strong  enough  to  use  her  toothbrush,  the 


AFTER-TREATMENT  5&9 

mouth  and  teeth  should  be  cleansed  with  pledgets  ot 
absorbent  wool  soaked  in  glyco-thymoline.  False  teeth 
should  not  be  replaced  till  the  morning  following  the 
operation,  and  not  then  if  the  patient  is  attacked  with 
sickness. 

Hair. — The  hair  should  be  brushed,  combed,  and 
plaited  twice  daily. 

Hands  and  face.  —  The  hands  and  face  should  be 
washed  with  warm  water  and  soap  thrice  daily,  at  7  a.m., 
2  p.m.,  and  7  p.m.  At  the  end  of  a  week  after  major 
operations,  if  she  so  desires,  the  patient  may  be  allowed 
to  wash  her  hands  and  face  herself. 

Body- — The  body  should  be  sponged  once  daily  with 
warm  water,  and  special  care  must  be  taken  to  cleanse  the 
perineal  region  each  time  after  the  patient  has  defalcated 
or  passed  water. 

Back. — On  the  morning  after  the  operation  the  shoulders 
and  back  of  the  patient  must  be  specially  treated. 

With  the  help  of  another  nurse  the  patient  is  gently 
turned  on  her  side.  The  shoulders  and  back,  which  now 
come  into  view,  are  first  sponged  with  warm  water,  then 
washed  with  eau-de-Cologne  or  methylated  spirit,  and 
lastly  dried  with  oxide  of  zinc  and  starch  powder  mixed 
in  equal  proportions.  This  should  be  done  twice  daily, 
at  7  a.m.  and  7  p.m. 

Dress. — The  patient  should  be  dressed  in  a  nightgown 
which  opens  down  the  back.  There  should  be  two  night- 
gowns in  use,  one  for  the  day  and  one  for  the  night.  She 
should  have  a  clean  nightgown  every  day,  and  oftener  if 
necessary,  and  these  may  be  so  arranged  that  the  clean 
nightgown  of  one  day  will  do  for  the  night  but  one  following. 
A  woollen  dressing- jacket  must  also  be  worn,  and,  to  save 
disturbing  the  patient,  it  can  quite  well  be  put  on  with 
the  back  to  the  front.  The  front  of  her  chest  should  be 
kept  covered  with  wool  or  Gamgee  tissue  if  the  room  is 
draughty  or  the  patient  inclined  to  bronchitis,  and  when  the 
operation  has  been  very  severe  it  is  best  to  let  the  patient 


570  GYNECOLOGICAL  SURGERY 

keep  on  her  drawers  and   stockings    for   the  first   twenty - 
four  hours  or  more. 

14.  Bed-clothes. — The  patient  has  a  blanket  next  to 
her  for  the  first  few  days  after  major  operations,  unless  the 
weather  is  very  hot  and  she  can  dispense  with  it.  It  is  very 
useful  when  there  is  much  shock. 

The  draw-sheet  is  changed,  as  a  routine,  twice  daily,  at 
7  a.m.  and  7  p.m.,  when  the  patient's  back  is  being  washed, 
and  at  any  other  time  when  it  is  soiled.  The  bottom  sheet 
is  changed  once  a  week  unless  soiled,  or  the  patient  desires 
and  can  afford  a  more  frequent  change.  The  top  sheet 
may  be  changed  according  to  the  pleasure  and  the  pocket 
of  the  patient  ;  if  there  are  sufficient  sheets,  a  clean  one 
can  be  used  daily,  and  it  is  best  to  have  two  in  use,  one  for 
day  and  one  for  night,  the  day  sheet  being  used  for  the 
following  night. 

15.  Medicine,  etc. — As  a  rule,  no  medicinal  treatment 
is  prescribed  for  patients  for  the  first  fortnight  after  an 
operation,  apart  from  aperients  or  any  other  drugs  which 
the  surgeon  may  order  for  some  particular  complications. 
After  a  fortnight,  a  tonic  may  be  indicated.  We  have 
found  a  hypodermic  injection  of  the  liquor  strychninae,  n\iii. 
twice  daily  for  the  first  week  after  severe  major  operations, 
to  be  very  beneficial,  and  have  seen  nothing  but  good 
from  its  use. 

16.  Belts. — We  are  not  in  the  habit  of  ordering  abdo- 
minal belts  for  our  patients  after  cceliotomy,  except  in  cases 
where,  owing  to  suppuration  of  the  wound,  a  ventral  hernia 
is  to  be  feared.  If  the  patient  can  afford  it,  it  will  be  best 
that  she  should  be  fitted  with  new  corsets,  as  the  shape  of 
the  abdomen  is  always  temporarily  altered  after  abdominal 
section.  The  corsets  should  be  made  long  in  front  and 
fastened  at  the  lower  edge  by  a  strap  to  keep  the  busks  flat 
on  the  abdominal  wall. 

17.  Visitors.  —  It  is  so  necessary  that  the  patient 
should  be  kept  quiet  after  a  major  operation,  that  ordinary 
visitors  should  not  be  allowed  to  see  her  for  the  first  week, 


AFTER-TREATMENT  571 

and  if  possible  the  husband  or  parents  should  be  kept 
away  for  the  first  three  days.  To  satisfy  the  nearest  rela- 
tives, one  of  them  may  be  allowed  to  see  the  patient  for  a 
few  seconds  after  the  operation,  when  she  is  back  in  bed, 
and  most  probably  still  under  the  influence  of  the  anaesthetic. 

18.  Postoperative  rest  in  bed. — Under  this  head  the 
surgeon  will,  of  course,  have  to  take  into  consideration 
the  general  condition  of  the  patient.  If  she  has  been  ill  for 
many  weeks  before  the  operation,  she  will  have  to  keep 
to  her  bed  longer  than  is  usual  for  the  particular  operation 
that  she  has  undergone,  and  if  any  complications  arise 
the  time  must  obviously  be  prolonged.  In  the  majority  of 
instances,  however,  the  patient  or  her  friends  may  be 
given  a  fair  idea  as  to  the  time  necessary  for  convalescence  ; 
and  this,  in  some  cases,  is  a  matter  of  much  importance,  as 
when  the  expenses  of  a  nursing-home  have  to  be  taken 
into  consideration. 

(a)  Minor  operations.  — ■  In  perineoplasty  and  colpor- 
rhaphy  cases  the  patient  gets  up  on  the  fourteenth  day. 

Curetting,  vulval,  vaginal,  and  cervical  operations.— -The 
patient  rises  on  the  tenth  day  if  all  loss  and  discharge  has 
stopped. 

(b)  Major  operations. — Surgeons  differ  as  to  when  they 
allow  their  patients  to  go  home  after  these  operations, 
the  time  varying  from  seventeen  to  twenty-eight  days. 
As  the  result  of  our  experience,  twenty-one  days  seems  to 
be  the  best  time  in  the  majority  of  cases. 

19.  Resumption  of  usual  occupation.  —  After  the 
majority  of  minor  operations,  patients  are  soon  able  to 
resume  their  normal  avocations.  When  the  operation  has 
been  performed  for  some  variety  of  prolapse  of  the  genital 
organs,  the  patient  should  be  warned  not  to  undertake 
for  some  time  any  work  or  exercise  which  will  necessitate 
straining  of  the  pelvic  floor. 

It  is  very  advisable  that,  after  a  major  operation,  every 
patient,  on  getting  up,  should  be  sent  away  for  at  least 
three  weeks  for  a  change  of  air,  and,  if  a  hospital  patient, 


572  GYNECOLOGICAL  SURGERY 

she  should  be  sent  to  a  convalescent-home,  since  there 
she  will  obtain  adequate  nursing.  After  a  major  operation 
the  patient  will  not  have  entirely  recovered  from  its  effects 
for  at  least  six  months,  during  which  time  she  should  take 
things  as  quietly  as  her  circumstances  will  permit.  On 
the  resumption  of  active  exercise,  she  should  be  careful 
for  some  months  longer,  whenever  possible,  to  avoid  any 
procedure  that  will  throw  much  strain  on  the  abdominal 
muscles. 


CHAPTER    XXXIII 

METHODS    OF    ADMINISTERING    SALINE 
SOLUTION 

Indications. — The  administration  of  saline  solution  may 
be  indicated  in  patients  suffering  from  haemorrhage, 
from  shock,  from  peritonitis,  or  from  suppression  of  urine. 
Composition  and  temperature  of  solution.  —  Normal 
saline  solution  is  made  by  adding  a  teaspoonful  of  sodium 
chloride  (table  salt)  to  a  pint  of  boiled  water.  The  tem- 
perature at  which  it  should  be  introduced  into  the  body 
should  be  about  ioo°  F.,  and,  as  it  loses  some  heat  in  its 
passage  to  the  body,  the  temperature  of  the  solution  in 
the  container  from  which  it  is  administered  should  be  1050  F.* 

METHODS   OF   ADMINISTRATION 

The  channels  through  which  the  solution  can  be  intro- 
duced into  the  body  are — • 

1.  The  veins. 

2.  The  subcutaneous  tissue. 

3.  The  rectum. 

4.  The  peritoneal  cavity. 

1.  Intravenous  Injection 

By  injecting  the  solution  into  the  veins,  the  fluid 
which  the  body  needs  is  at  once  added  to  the  circulation, 
and  this  is,  therefore,  the  best  method  in  urgent  cases. 

Preparation  of  the  patient. — Any  vein  may  be  chosen, 
but  as  a  matter  of  practice  one  of  the  veins  at  the  bend 
of   the  elbow,  the   median-basilic  or   the  median-cephalic, 

*  Lazarus  Barlow,  on  experimental  grounds,  recommends  a  glucose  solu- 
tion (Arch.  Middx.  Hosp.,  xvi.  23). 

573 


574 


GYNECOLOGICAL  SURGERY 


whichever  is  the  more  prominent,  is  generally  chosen.  The 
skin  covering  this  region  is  rendered  as  aseptic  as  time  will 
admit  of  by  vigorous  scrubbing  with  soap  and  water,  and 
afterwards  with  biniodide  of  mercury  solution,  i — 2,000. 

Instruments.— A  scalpel,  dissecting  forceps,  pair  of 
pressure-forceps,  aneurysm-needle,  No.  2  silk  ligatures,  and 
some  sort  of  a  bandage  to  constrict  the  upper  arm  are 
required,  in  addition  to  some  form  of  transfusion  apparatus, 

which  must 
consist  of  a 
receptacle  for 
the  solution, 
an  india-rub- 
ber tube,  a 
cannula  with 
the  opening  at 
the  end — not 
in  the  side — 
to  insert  into 
the  vein,  and  a 
thermometer. 
An  irrigating 
porringer  will 
do  very  well 
as  a  receptacle 
if  the  surgeon 

has  a  cannula.  The  injection  apparatus  devised  by  one 
of  us  (Fig.  22),  which  contains  all  that  is  necessary,  will 
be  found  very  useful  for  private  work.  Soloids  of  chemi- 
cally pure  sodium  chloride  can  be  obtained  of  a  sufficient 
strength  for  one  to  a  pint  of  water  to  make  a  normal  saline 
solution.  The  solution  must  be  mixed  in  a  jug,  from 
which  it  is  poured  into  the  receptacle. 

Operation,  i.  Isolating  the  vein. — The  arm  having  been 
sufficiently  bandaged  4  in.  above  the  elbow  to  stop  the 
return  of  the  venous  blood,  and  so  make  the  veins  stand 
out,   and  the   most  prominent   vein  having  been    chosen, 


Fig.   380. — Intravenous  saline  infusion 
Isolating  the  vein. 


ADMINISTERING  SALINE  SOLUTION      575 


the  skin  over  it  is  incised  in  the  line  of  the  vein,  which  is 
then  separated  from  the  tissues  surrounding  it  (Fig.  380). 

ii.  Ligaturing 
the  lower  end  of 
the  vein. — Three 
ligatures  of  silk 
are  passed  under 
the  vein  by  means 
of  an  aneurysm- 
needle  or,  what 
will  do  equally 
well,  a  Bonney's 
needle  used  with 
the  blunt  end  first. 
One  ligature  is  tied 
at  the  distal  end 
of  the  separated 
vein,  the  second 
is  used  for  tying- 
in  the  cannula,  and  the  third  is  reserved  to  ligature  the  prox- 
imal end  of  the  vein  at  the  end  of  the  operation  (Fig.  381) 

iii.  Opening  the  vein. — The  vein  is  picked  up  with  the 


Fig.  381. — Ligaturing  the  lower  end 
of  the  vein. 


Fig.  382. — Opening  the  vein. 

dissecting  forceps,  and,  a  longitudinal  opening  having  been 
made  in  it  with  the  point  of   the  scalpel   (Fig.   382),  the 


5?b 


GYNECOLOGICAL  SURGERY 


cannula  is  inserted  into  its  lumen.  A  little  of  the  saline 
injection  should  be  allowed  to  flow  through  while  it  is 
being  introduced,  so  that  all  air-bubbles  may  be  expelled, 


Fig.  383. — Inserting  the  cannula. 

and,  the  blood  having  been  washed  away,  the  opening  in 
the  vein  is  easily  seen  (Fig.  383). 

iv.  Securing  the  cannula. — When  the  cannula  is  in  the 
vein  the  second  ligature  is  tied  tightly  to  keep  it  in  position, 

after  which  the 
bandage  round 
the  arm  is  re- 
moved and  the 
saline  solution 
allowed  to  run 
into  the  vein 
(Fig.  384).  The 
amount  of  fluid 
run  in  will  de- 
pend upon  what 
the  injection  is 
being  used  for,  and  will  vary  from  two  to  five  pints. 
The  receptacle  containing  the  solution  must  not  be  al- 
lowed to  become  empty.     If  by  chance  this  should  occur, 


Fig.  384. — The  cannula  secured. 


ADMINISTERING   SALINE  SOLUTION     577 

the  tube  must  be  at  once  pressed  with  the  finger  and  thumb 
to  prevent  air  from  entering  the  vein.  The  ligature  securing 
the  cannula  is  cut  when  sufficient  solution  has  been  injected, 
and  the  third  ligature  is  tied  as  the  cannula  is  withdrawn, 
after  which  one  or  two  interrupted  silk  sutures  unite  the 
skin-wound. 

Difficulties. — Although  this  operation  is  apparently  so 
simple,  we  have  not  infrequently  seen  the  attempt  to 
introduce  the  cannula  into  the  vein  utterly  fail.  This  is 
owing  to  the  trying  circumstances  in  which  it  has  most 
often  to  be  performed,  the  surgeon  in  his  hurry  omitting 
the  careful  performance  of  the  technique  we  have  just 
described.  Frequently  the  skin-incision  made  is  too  small, 
and  time  is  wasted  in  identifying  the  vein.  The  vein, 
instead  of  being  freed,  may  be  merely  exposed  and  opened 
without  the  previous  application  of  the  distal  ligature. 
The  free  flow  of  blood  that  then  occurs  prevents  the 
operator  from  seeing  the  hole  through  which  he  must  pass 
the  cannula,  and  he  is  further  unable  to  lift  the  vein 
out  of  the  wound  so  as  to  see  clearly  what  he  is  doing. 
The  result  is  that  he  more  often  than  not  passes  the 
cannula  into  the  perivenous  sheath  instead  of  into  the 
vein  itself. 

In  other  cases  the  preliminary  bandage  round  the  upper 
arm  may  be  forgotten,  so  that  if  the  patient  be  much 
exsanguinated  the  vein  merely  presents  as  a  flat  white 
strap  which  it  is  very  difficult  properly  to  open,  or  into 
which,  being  opened,  it  is  difficult  to  get  the  cannula.  If 
in  spite  of  every  precaution  the  fluid  cannot  be  introduced 
into  the  vein  chosen,  some  other  vein  must  be  tried.  It 
may  be  remarked  that  if  the  patient  is  much  collapsed 
the  fluid  at  first  flows  very  slowly;  as  the  circulation 
improves,  the  rate  will  increase. 

Dangers. — -The  most  important  fact  to  remember  in 
connection  with  intravenous  injection  is  that  in  cases  of 
haemorrhage  it  should  never  be  given  until  the  bleeding-spot 
has   been   secured.     We   have   several   times    seen    cases    in 

2  L 


578  GYNAECOLOGICAL  SURGERY 

which  nearly  all  the  blood  of  the  body  had  been  washed 
into  the  peritoneal  cavity  for  this  reason. 

Great  care,  of  course,  must  be  taken  that  no  air  is 
injected  with  the  solution,  on  account  of  the  danger  of  an 
air-embolism.  The  solution  and  the  instruments  should 
all  be  aseptic.  If  too  much  solution  is  injected  the 
patient  may  get   cedema  of  the  lungs. 

Lastly,  the  solution  must  be  of  a  proper  temperature, 
and  the  nurse  must  keep  testing  the  fluid  in  the  re- 
ceptacle with  a  thermometer,  and  adding  hot  solution  as 
required. 

Dressings. — Some  gauze,  wool,  and  a  bandage. 

After-treatment.- — The  skin-stitches  are  taken  out  at 
the  end  of  a  week. 

2.  Subcutaneous  Injection 

With  this  method  the  solution  is  introduced  into  the 
cellular  tissue  of  the  body,  and  is  thence  absorbed  into  the 
circulation.  It  is  a  slower  method  than  intravenous  injec- 
tion, and  the  solution  should  be  hotter — at  a  temperature 
of  about  1080  F. 

Site  of  injection. — The  most  usual  place  to  run  in  the 
saline  solution  is  under  the  breasts  ;  it  can  also  be  run 
in  under  the  axillae,  or  just  above  the  crest  of  the  ilium. 

Preparation  of  the  patient.  —  The  skin  over  the  site 
of  injection  is  prepared  as  for  intravenous  injection. 

Instruments. — A  receptacle  for  the  solution,  an  aspirat- 
ing needle  attached  to  a  glass  funnel  by  a  4-ft.  length  of 
india-rubber  tubing,  and  a  thermometer  are  required. 

Operation. — At  the  spot  chosen  the  aspirating  needle 
is  introduced,  allowing  a  little  of  the  solution  to  run  out 
during  its  insertion. 

About  a  pint  can  be  run  in  under  each  breast,  and 
the  dose  can  be  repeated,  if  necessary,  after  the  first  lot  has 
absorbed. 

Dressing.  —  Some  collodion  and  gauze  over  the  point 
of  insertion  of  the  needle. 


ADMINISTERING  SALINE  SOLUTION     579 


CONTINUOUS   SALINE   INFUSION 

This  is  an  extension  of  the  method  just  described.  The 
fluid  is  run  in  by  syphon  action  from  a  large  receptacle 
through  an  india-rubber  tube  to  which  is  attached  an 
aspirating  needle,  or,  better  still,  a  T-piece  of  glass  with 
two  tubes,  each  furnished  with  a  needle  (Fig.  385). 


Fig.  385. — Continuous  infusion  into  the  cellular  tissue. 

The  sides  of  the  chest  or  the  thighs  are  the  sites  usually 
selected.  The  needles  should  be  run  well  into  the  cellular 
tissue  and  retained  there  by  strips  of  adhesive  strapping. 
The  receptacle  should  be  but  slightly  raised  above  the 
level  of  the  patient  so  that  the  inflow  is  slow,  from  about 
half  a  pint  to  a  pint  an  hour,  a  faster  rate  than  this  usually 
soon  producing  much  oedema.  If  the  apparatus  works 
satisfactorily,  from  10  to  20  pints  may  be  introduced  in 


580  GYNECOLOGICAL  SURGERY 

twenty-four  hours.  It  is  necessary  to  have  a  nurse  con- 
stantly in  attendance  to  see  that  the  temperature  of  the 
fluid  in  the  receptacle  does  not  fall  below  1080  F. 

Where  two  needles  are  employed  it  is  an  admirable 
plan  to  apply  a  stopcock  or  a  pressure-forceps  to  each  of 
the  tubes  connecting  them  with  the  T-piece.  Each  needle 
can  then  be  used  alternately,  the  inflow  being  cut  off  directly 
the  tissues  in  the  neighbourhood  begin  to  get  cedematous. 

It  is  very  important  to  sterilize  the  skin  as  carefully  as 
possible  before  introducing  the  needles  ;  and  the  water  with 
which  the  saline  solution  is  made  should,  of  course,  be  boiled. 

This  method  of  administering  saline  solution  is  highly 
praised  in  the  treatment  of  peritonitis  and  conditions  in 
which  administration  of  fluid  by  the  mouth  or  the  rectum 
is  impossible. 

3.  Peritoneal  Administration 
Some  surgeons  make  a  point  after  every  abdominal 
operation,  and  before  closing  the  abdomen,  of  pouring  into 
the  peritoneal  cavity  two  or  three  pints  of  saline  solution. 
Others  employ  this  method  only  if  there  has  been  much 
haemorrhage.  It  is  certainly  an  excellent  method  to  adopt 
if  the  abdominal  cavity  has  had  to  be  reopened  for 
secondary  hsemorrhage,  or  if  the  operation  has  been  a 
prolonged  one  involving  much  shock,  as,  for  instance, 
the  radical  abdominal  operation  for  cancer  of  the  cervix. 
Instruments.  —  A  jug  to  contain  the  solution,  and  a 
thermometer. 

Injection. — -Three  pints  of  salt-solution  at  a  tempera- 
ture of  1050  F.  are  mixed  in  the  jug,  and  the  fluid  is  then 
poured  straight  into  the  abdominal  cavity  just  before  the 
last  two  inches  of  abdominal  peritoneum  is  sutured.  The 
patient  should  be  tilted  a  little  so  that  the  solution  may 
not  escape  before  the  wound  is  closed. 

4.  Rectal  Injection 
Rectal  injections  of  saline  solution  are  used  as  a  routine 
measure  to  relieve  the  thirst  after  an  abdominal  section. 


ADMINISTERING  SALINE  SOLUTION     581 

They  are  also  used  as  a  means  of  introducing  fluid  in  cases 
where  there  has  been  considerable  hsemorrhage  during  the 
operation,  but  not  sufficient  to  indicate  venous  infusion, 
and  in  cases  of  prolonged  operation  involving  shock. 

This  method  may  also  be  employed  as  an  additional 
means  of  supply  after  intravenous  injection  has  been  per- 
formed. It  is  a  most  useful  method,  and  as  a  routine 
performance  after  severe  operations  gives  admirable  results. 
In  cases  where  much  loss  of  blood  during  the  operation  is 
anticipated,  it  is  good  practice  to  administer  a  high  rectal 
injection  of  a  pint  of  saline  solution  one  hour  before  the 
operation. 

Instruments. — The  glass  funnel  attached  to  a  No.  12 
india-rubber  catheter  and  a  receptacle  to  hold  the  solution, 
which  should  be  administered  at  a  temperature  of  ioo°  F. 

Injection. — Before  the  return  of  consciousness  a  pint 
or  more  can  be  introduced  into  the  bowel,  but  after  the 
effect  of  the  anaesthetic  has  worn  off  the  rectum  will  only 
tolerate  6  ounces.  More  than  this  can  be  injected  by 
introducing  a  long  rectal  tube  as  high  up  as  it  will  go,  and 
running  the  solution  into  the  colon,  but  this  is  seldom 
indicated  in  pelvic  surgery,  since  distension  of  the  sigmoid 
colon  may  adversely  affect  the  operation  area.  As  a  rule, 
6  ounces  are  injected  every  two  hours  for  the  first  few 
hours,  then  every  four  hours  for  the  next  twenty-four, 
unless  the  condition  of  the  patient  demands  a  more  frequent 
administration.  The  best  time  for  the  injection  is  after 
the  rectal  tube  has  been  passed  to  relieve  flatus,  when  the 
tube,  without  withdrawal,  may  be  used  to  administer 
the  injection.  If  the  patient's  condition  indicates  stimu- 
lants, brandy  may  with  advantage  be  added  to  the  saline 
solution.  Continuous  administration  can  be  effected  by 
a  modification  of  the  syphon  apparatus  described  in  the 
section  dealing  with  infusion  into  the  cellular  tissue  (p.  579). 

Where  the  bowel  low  down  has  been  injured  in  the 
course  of  the  operation,  rectal  injections  should  not  be 
given,  for  fear  of  rupturing  it. 


CHAPTER    XXXIV 
POSTOPERATIVE    COMPLICATIONS 

VOMITING 

Postoperative    vomiting   may  be   considered   under   the 
following  headings  : — 

1.  Anaesthetic  vomiting. 

2.  Irritative  vomiting. 

3.  Neurotic  vomiting. 

4.  Peritonitic  vomiting. 

5.  Obstructive  vomiting. 

6.  Vomiting  due  to  acute  dilatation  of  the  stomach. 

7.  Vomiting  due  to  pylephlebitis. 

1.  Anaesthetic  yomiting. — This  occurs  soon  after  the 
patient  has  been  put  back  to  bed.  It  is  partly  dependent 
on  the  patient,  partly  on  the  nature  of  the  anaesthetic  used, 
partly  on  the  experience  of  the  anaesthetist,  and  partly  on 
the  method  of  preparation  of  the  patient.  Some  patients 
vomit  at  the  least  provocation,  such  as  a  bad  smell,  a  bad 
taste,  the  sight  of  anything  objectionable,  or  slight  pain. 
Chloroform  will  suit  one  patient,  and  ether  another.  It  is 
a  matter  of  everyday  observation  that  patients  vomit 
much  less  when  the  anaesthetic  is  administered  by  one 
experienced  in  this  class  of  work,  and  also  that  if  an  anaes- 
thetic is  administered  before  the  stomach  is  empty  vomit- 
ing will  most  likely  ensue.  Anaesthetic  vomiting,  as  a  rule, 
does  not  last  more  than  a  few  hours,  and  the  vomited 
matter  consists  of  bile-stained  fluid. 

The  nurse  should  stay  by  the  patient  and  keep  her 
from  being  soiled  by  any  ejected  material.  The  patient 
should  be  placed  on  her  side  in  minor  operations,  and  in 
major  cases  the  head  must  be  turned  to  one  side. 

582 


POSTOPERATIVE  COMPLICATIONS        583 

2.  Irritative  vomiting. — This  is  due  to  a  gastritis  set 
up  by  the  anaesthetic.  The  contents  of  the  stomach  are 
persistently  ejected,  but  vomiting  is  not  so  likely  to  occur 
if  the  viscus  be  left  alone  and  not  continually  worried  by 
milk  or  beef -tea  being  poured  into  it.  Irritative  vomiting 
is  often  combined  with  flatulent  gastric  distension,  and 
pain  referred  to  the  left  thorax.  Large  quantities  of  bile 
may  be  brought  up — the  so-called  "  bilious  "  vomiting. 
There  is  no  abdominal  tenderness,  fever,  or  undue  rapidity 
of  the  pulse. 

The  treatment  is  to  add  lime-water  to  the  milk  or  to 
peptonize  it. 

This  prescription  will  be  found  useful  : — 

ty     Sodse  bicarb.  3*- 

Ess.  menth.  pip.  Tl\y. 
Aq.  calid,  ad  §iii. 
To  be  administered  half  an  hour  before  the  next  feed. 

This  draught,  which  at  times  makes  the  patient  very 
sick,  and  so  effectually  washes  out  the  stomach,  often 
gives  great  relief. 

The  following  also  may  be  tried  : — 

ty     Bismuthi  carb.  gr.  v. 
Mag.  carb.  levis  gr.  x. 
Soda^  bicarb,  gr.  xv. 
Aq.  destil.  ad  §j. 
The  draught  to  be  taken  every  three  hours  if  necessary. 

If  the  vomiting  prove  obstinate,  feeding  by  the  mouth 
should  be  stopped  for  a  few  hours,  and  rectal  injections 
(p.  581)  meanwhile  administered.  There  is  one  remedy 
which  rarely  or  never  fails  to  stop  this  form  of  vomiting, 
and  that  is  a  soap-and-water  enema.  A  certain  degree  of 
"  polarity  "  doubtless  exists  between  the  two  ends  of  the 
intestinal  tract,  and,  without  doubt,  the  surest  way  to 
check  irritative  vomiting  is  to  open  the  bowels. 

Irritative  vomiting  does  not,  as  a  rule,  last  more  than 
twenty-four  hours.     It  is  not  at  all  uncommon  in  the  more 


584  GYNAECOLOGICAL  SURGERY 

severe  classes  of  irritative  vomiting  for  the  ejected  material 
to  be  "  coffee-coloured  "  from  the  presence  in  it  of  altered 
blood,  derived  probably  from  the  congested  stomach-wall. 
In  the  absence  of  unfavourable  abdominal  symptoms,  this 
occurrence  need  not  give  alarm. 

3.  Neurotic   vomiting. — This    is    often    combined    with 
the  foregoing,  but  when  due  to  neurosis  pure  and  simple 
it  may  be  very  troublesome.     The  patient  is  continually 
retching,  whether  food  be  in  the  stomach  or  not — she  is 
obviously  trying   to   be   sick.     There   are   no   other   signs 
suggesting   anything   amiss  :     the   pulse   is   not   quickened 
to  any  marked  degree,  there  is  no  abdominal  distension, 
and  the  quantity  of  the  fluid  evacuated  does  not  increase  ; 
in  fact,  the  presence  of  neurotic  vomiting  is  usually  noticed 
in  those  in  whom  there  is  the  least  likelihood  of  any  grave 
lesion  of  the  bowel  or  peritoneum.     A  good  "  talking-to  " 
will  often  act  as  a  cure,  if  everything  else  fails.     We  have 
found  that  the  addition  of  a  little  brandy  to  the  food  often 
tempts  the  patient  to  retain  it,  as  in  these  cases  there  may 
be  a  craving  for  alcohol  or  morphia.     Neurotic  vomiting 
can  be  troublesome  for  several  days,   and  if  not  relieved 
the  patient  may  be  much  exhausted.     The  remedies  men- 
tioned under  "irritative  vomiting"  (p.  583)  may  be  tried, 
and  in  addition  relief  may  sometimes  be  obtained  by  counter- 
irritants,  such  as  an  ice-bag,  mustard-plaster,  or  blister  over 
the   epigastrium.     Drop-doses    of   tincture   of   iodine   in   a 
teaspoonful  of  hot  water  every  half-hour,  iced  champagne, 
very  strong  coffee  without  milk,   an  enema  of   20  grains 
of   chloral  hydrate   in  3   ounces   of  water,   all  these  may 
relieve    the   patient,  or,  on   the    other .  hand,  may  not   be 
of    the    slightest    use.      If    the    condition    becomes    very 
troublesome,    relief    will    only   be    obtained    by   stopping 
all   food   by   the   mouth,    washing   out   the   stomach,    and 
opening    the    bowels    by    a    simple    enema    of    soap-and- 
water. 

If  the  patient  is  very  excitable,  half  a  grain  of  morphia 
will  very  often  change  the  aspect  of  affairs  entirely,  and 


POSTOPERATIVE  COMPLICATIONS        585 

the    patient  will    wake     up    relieved    of    this    troublesome 
symptom. 

4.  Peritonitic  vomiting.  —  This  comes  on  during  the 
second  or  third  day  following  the  operation.  The  vomiting 
is  at  first  infrequent  and  the  amount  small,  while  the 
ejected  material  is  pale-brown  in  colour.  Later  it  is  a 
darker  brown  or  green,  and  sometimes  slightly  offensive, 
while  the  amount  may  be  very  considerable,  the  patient 
vomiting  as  much  as  half  a  pint  at  a  time  ;  but  there  is  no 
feeling  of  sickness  nor  effort  to  eject  the  fluid  as  in  the 
case  of  irritative  vomiting  ;  the  fluid  simply  wells  up  and 
flows  out  of  the  mouth.  The  other  signs  and  symptoms 
which  accompany  peritonitis  are,  as  a  rule,  so  evident  that 
the  cause  of  the  vomiting  cannot  be  mistaken. 

The  treatment  will  be  described  under  Peritonitis  (p.  601). 

5.  Obstructive  vomiting. — If  a  portion  of  the  intestinal 
canal  becomes  occluded,  as  the  result,  immediate  or  remote, 
of  the  operation,  obstructive  vomiting  supervenes.  This 
may  be  due  to  many  causes,  of  which  a  list  is  given 
at  p.  606,  but,  whatever  the  cause,  the  result  is  the  same. 
Obstructive  vomiting  comes  on  quite  gradually,  so  that 
for  the  first  two  or  three  days  the  patient  may  apparently 
be  progressing  quite  satisfactorily.  Later  the  vomiting, 
which  at  first  is  only  intermittent,  gradually  increases  in 
frequency,  till  at  last  it  is  practically  continuous.  Although 
faecal  vomiting  is  said  to  be  diagnostic  of  obstruction,  the 
ejected  material  often  does  not  become  faecal  in  character 
until  the  end  is  at  hand,  unless  the  obstruction  is  very 
high  up,  and  in  many  instances  it  does  not  become  faecal 
at  all. 

Obstructive  vomiting  is  always  accompanied  by  dis- 
tension, which  gradually  becomes  more  and  more  marked, 
commencing,  as  a  rule,  over  the  left  abdomen,  the  seat  of 
the  obstruction  being  usually  in  the  region  of  the  sigmoid 
flexure. 

The  remaining  signs  and  symptoms  of  obstruction  are 
described  at  pp.  608  and  613. 


586  GYNECOLOGICAL  SURGERY 

In  peritonitic  and  obstructive  vomiting  it  is  most 
important  to  note  that  the  large  amount  vomited  is  out  of 
all  proportion  to  any  fluid  that  may  have  been  introduced 
into  the  stomach  by  the  mouth,  whilst  its  character  shows 
that  it  is  not  the  normal  secretion  of  the  stomach  and 
upper  part  of  the  duodenum.  It  is,  in  fact,  due  to  an  acute 
bacterial  invasion  of  the  stomach  and  intestinal  wall, 
resulting  in  a  copious  watery  secretion  therefrom.  The 
fseculent  odour  of  obstructive  vomiting  is  due  to  acute 
infection  of  the  upper  intestinal  tract  by  the  Bacillus  coli 
communis  and  other  intestinal  bacteria. 

6.  Vomiting  due  to  acute  dilatation  of  the  stomach. — 
See  p.  622. 

7.  Vomiting  due  to  pylephlebitis. — See  p.  619. 

DISTENSION 

Abdominal  distension  after  operation  is  either  (1)  epi- 
gastric, (2)  flatulent,  (3)  paretic,  (4)  obstructive,  or  (5) 
peritonitic. 

1.  Epigastric  distension. — This  is  often  associated  with 
irritative  vomiting  and  owns  the  same  cause.  It  is  obviously 
gastric,  and  the  treatment  suggested  for  irritative  vomiting 
may  be  tried.  If  these  measures  fail,  the  remedies  recom- 
mended under  neurotic  vomiting  may  be  used. 

A  distended  transverse  colon  may  be  mistaken  for  the 
stomach  if  the  abdomen  be  examined  without  the  bandage 
being  unfastened.  This  would  be  a  serious  error,  since  a 
distended  colon  has  a  very  different  significance. 

2.  Flatulent  distension. — For  forty-eight  hours  after  all 
abdominal  sections,  more  or  less  flatulent  distension  of  the 
intestine  occurs.  It  begins  in  the  stomach  (epigastric  dis- 
tension) and  gradually  works  its  way  downwards,  being 
accompanied  in  the  earlier  hours  by  intermittent  explosions 
per  os,  and  later  on  per  anum.  It  is  probably  due  to  the 
altered  relations  and  pressure-changes  obtaining  in  the 
abdominal  cavity  as  the  result  of  the  operation.  The 
patient   is   made   unpleasantly   aware    of   its   presence   by 


POSTOPERATIVE  COMPLICATIONS        587 

painful  borborygmi,  and  relief  is  not  obtained  until  the 
gas  freely  escapes  from,  the  rectum.  Such  passage  of  flatus 
rarely  occurs  naturally  until  forty-eight  hours  after  the 
operation,  but  its  passage  by  the  rectal  tube  should  be 
evident  after  twenty-four  hours.  A  certain  amount  of 
discomfort  is  to  be  expected  after  all  abdominal  operations, 
but  it  is  minimized  considerably  by  the  regular  use  of  the 
rectal  tube  as  described  at  p.  556. 

3.  Paretic  distension. — This  in  its  lesser  degrees  is  a 
not  uncommon  condition,  especially  when  the  operation  has 
been  at  all  prolonged  and  there  has  been  much  handling  of 
the  intestines.  The  distension  is  uniform  and  soft  ;  there 
is  no  rigidity  or  tenderness  of  the  abdominal  walls,  and  it 
is  a  general  distension  not  markedly  beginning  in  or  localized 
to  one  section  of  the  gut.  Although  a  degree  of  irritative 
vomiting  not  uncommonly  accompanies  it  at  first,  the 
pulse  and  temperature  are  not  unfavourable.  Its  danger 
chiefly  lies  in  the  possibility  of  the  distension  causing  a 
kink  in  some  portion  of  the  bowel  tethered  by  adhesion  or 
shortening  of  its  mesentery,  and  thus  producing  a  real 
obstruction.  Exceptionally,  however,  the  degree  of  para- 
lysis of  the  gut  may  be  such  that  complete  obstruction 
results.  This  important  complication  is  fully  dealt  with 
under  the  head  of  Intestinal  Obstruction  (p.  613).  In  true 
paretic  distension  there  is  a  complete  absence  of  painful 
intestinal  movements  and  borborygmi. 

Paretic  distension  is  to  be  treated  by  frequent  applica- 
tion of  the  rectal  tube,  by  a  turpentine  or  rue  enema,  or 
by  a  rectal  wash-out. 

Enemata. — A  turpentine  enema  consists  of  turpentine 
§ss,  olei  ricini  §i,  soap-and-water  Oi,  and  is  made  either  by 
mixing  the  turpentine  in  a  porringer  with  a  piece  of  soft  soap 
as  large  as  a  hen's  egg,  then  stirring  in  the  oil,  and  lastly 
adding  the  remaining  ingredients,  or  by  beating  up  the 
turpentine  with  the  white  of  an  egg  and  then  stirring  in 
the  other  ingredients.  The  enema  should  be  injected  at  a 
temperature  of  1020  F. 


5S8  GYNECOLOGICAL  SURGERY 

A  rue  enema  consists  of  olei  rutae  n\xx,  mucilag.  acacise 
3ii,  soap-and-water  ad  3vi. 

In  either  case,  if  the  enema  is  not  returned  the  rectal 
tube  should  be  passed  to  draw  it  off. 

Rectal  wash-out. — To  wash  out  the  rectum  a  special 
tube  is  passed  (p.  536),  with  a  glass  funnel  fitted  to  its  free 
end.  Two  pints  of  soap-and-water  at  a  temperature  of 
1050  F.  should  have  been  mixed  with  one  ounce  of  turpen- 
tine, and  ten  ounces  of  this  solution  is  poured  into  the 
funnel,  which  is  held  as  high  as  possible.  The  fluid  is  then 
allowed  to  remain  in  the  rectum  for  a  few  minutes,  after 
which  the  funnel  is  lowered  into  a  basin  of  boric-acid  solution 
and  the  injection  allowed  to  run  out  with  a  consequent 
aspiration  of  flatus  from  the  intestine.  Another  ten  ounces 
is  run  in  until  the  two  pints  is  used  up.  As  a  rule  this 
method  of  treating  the  distension  is  very  successful.  It 
has  the  advantage  over  an  enema  that  it  does  not  exhaust 
the  patient  so  much. 

If  the  distension  is  due  to  simple  paresis  of  the  intestinal 
walls,  treatment  by  one  or  other  of  these  methods  will 
nearly  always  relieve  it,  and  we  have  found  the  most  useful 
of  them  to  be  the  rectal  tube  and  rectal  wash-out. 

Eserine  and  strychnine.— A  useful  adjunct  to  the  fore- 
going methods  is  the  hypodermic  injection  of  eserine  and 
strychnine,  the  first  of  which  has  certainly  a  specific  action 
in  restoring  tone  to  the  intestinal  wall.  For  this  purpose 
it  should  be  given  in  doses  of  TJ0  grain  combined  with  ^0- 
grain  of  strychnine  every  four  hours.  Pituitary  extract  is 
said  to  produce  the  same  result. 

4.  Obstructive  distension. — In  this  variety  the  abdomen 
is  hard  and,  when  due  to  an  organic  cause,  tender,  while 
the  condition  is  accompanied  by  persistent  vomiting,  and 
after  a  while  an  increasing  pulse-rate  and  a  rise  of  tempera- 
ture. In  pelvic  surgery  the  site  of  the  obstruction  is  most 
commonly  at  the  sigmoid  flexure,  and  it  is  important  to 
realize  that  it  is  most  often  a  partial,  not  a  complete 
obstruction.     The  symptoms,  therefore,  are  subacute,  and 


POSTOPERATIVE  COMPLICATIONS       589 

perhaps  it  may  be  a  week  or  even  more  before  a  fatal 
termination  is  reached.  The  distension  usually,  there- 
fore, commences  and  is  most  marked  in  the  descending 
colon  and  sigmoid,  and  over  the  latter  there  are  invariably 
some  rigidity  and  tenderness.  It  is  a  slow  progressive 
distension  first  of  the  large  and  then  of  the  small  bowel. 
The  distension  is  at  first  slight,  and  flatus  and  even  some 
small  bits  of  faecal  matter  may  be  passed  if  the  obstruction 
is  incomplete.  In  spite  of  this,  however,  the  symptoms  in- 
crease, the  vomiting,  which  at  first  occurred  only  at  long 
intervals,  increases  in  frequency  until  it  becomes  continu- 
ous, while  the  ejected  matter,  which  at  the  commence- 
ment consisted  only  of  food,  towards  the  close  may  be 
stercoraceous,  although  this  is  by  no  means  always  the  case. 

For  a  further  discussion  of  the  symptoms  of  intestinal 
obstruction  and  its  treatment,  see  p.  606. 

5.  Peritonitic  distension.- — This  form  of  distension,  when 
the  peritonitis  causing  it  is  acute  and  general,  is  diagnosed 
with  greater  ease,  accompanied  as  it  is  by  marked  pain, 
rigidity,  and  early  collapse.  The  treatment  is  most  hope- 
less when  the  symptoms  are  marked,  and  we  look  upon  the 
late  Mr.  Lawson  Tait's  plan  of  administering  sulphate  of 
magnesia  every  hour  until  the  bowels  are  opened  as  quite 
useless,  not  to  say  impracticable,  since  the  patient  will  not 
retain  it  in  her  stomach,  and  her  torments  are  increased  by 
the  vomiting  which  is  instantly  induced  by  putting  anything 
into  that  viscus.  Washing  out  the  stomach,  as  advised  by 
some  authorities  for  the  persistent  vomiting  accompanying 
this  condition,  is  worse  than  useless,  since  it  merely  further 
exhausts  the  unfortunate  patient.  Rectal  feeding,  together 
with  frequent  rectal  wash-outs  and  the  administration  of 
eserine  to  reduce  if  possible  the  distension,  in  addition  to 
the  treatment  described  in  the  section  dealing  with  peri- 
tonitis (p.  598),  is  the  proper  course  to  pursue. 

In  conclusion,  we  should  like  to  direct  special  attention 
to  the  value  of  rectal  saline  injections  in  the  treatment 
of    vomiting    and    distension.      After    giving    an   extended 


590  GYNECOLOGICAL  SURGERY 

trial  to  all  other  methods,  we  have  found  that  there  is  no 
procedure  that  is  so  generally  useful  as  this.  If  the  vomit- 
ing be  simply  irritative,  rectal  saline  injections  rest  the 
stomach  ;  if  it  be  due  to  partial  obstruction,  paretic  or 
otherwise,  the  bowel  has  time  to  recover  itself  ;  if  to  peri- 
tonitis, peristalsis  is  minimized,  and  thereby  assists  in  keep- 
ing the  inflammatory  process  localized  to  the  operation- 
site  ;  and  the  same  advantages  apply  to  cases  of  obstinate 
distension. 

We  resort  to  this  method  of  treatment  early  in  any 
case  of  vomiting  or  distension  that  does  not  rapidly  improve 
under  the  other  measures  we  have  indicated.  Its  applica- 
tion is  also  of  considerable  diagnostic  value,  since  vomiting 
which  continues  in  spite  of  the  rigid  exclusion  of  everything 
from  the  stomach  is  of  very  bad  import. 

PAIN 

After  all  abdominal  sections,  patients  complain  more  or 
less  of  pain  in  the  back  and  abdomen  for  a  period  of  at 
least  twenty-four  hours.  The  pain  should  then  rapidly 
subside,  so  that  at  the  end  of  forty-eight  hours  the  patient 
is  much  easier.  Pain  in  the  back  can  be  greatly  relieved 
by  putting  a  pillow  under  the  legs,  which  causes  the  back 
to  lie  flat  on  the  bed,  and  not  arched  as  is  otherwise  the 
case.  In  cases  where  this  fails,  an  air-cushion  put  under 
the  back  often  gives  relief. 

Pain  in  the  abdomen  is  most  marked  in  operations 
where  tension  on  the  stitches  is  likely  to  be  present,  such 
as  ventro-suspension,  or  where,  after  the  enucleation  of  a 
broad-ligament  cyst,  the  sac  is  stitched  to  the  anterior 
abdominal  wall  and  drained. 

The  single-layer  method  of  closing  the  abdominal  wound 
results  in  more  pain  than  the  three-layer  method,  and  an 
incision  through  the  abdominal  muscles  is  followed  by 
more  pain  than  one  through  the  linca  alba. 

A  discussion  of  this  symptom  centres  round  the  advis- 
ability of  giving  morphia  after  abdominal  section.     It  is 


POSTOPERATIVE  COMPLICATIONS        591 

better,  if  possible,  to  avoid  giving  morphia,  as  this  drug 
may  irritate  the  stomach,  and  many  patients  are  very 
sick  after  its  administration,  whilst  it  also  tends  to  increase 
the  thirst  from  which  the  patient  suffers. 

If  morphia  is  to  be  given  at  all,  it  should  be  given  on 
the  first  night,  for  three  reasons  :  (1)  because  the  pain  is 
at  its  worst ;  (2)  because  distension,  which  morphia  directly 
favours,  never  comes  on  until  twenty-four  hours  after 
operation ;  and  (3)  because  peritonitis  and  obstruction,  which 
are  masked  by  morphia,  do  not,  as  a  rule,  declare  them- 
selves until  the  second  day.  Therefore,  if  morphia  is 
indicated,  it  should  be  given  on  the  first  night  in  the  form 
of  a  suppository  or  hypodermic  injection.  Its  routine  use 
is  to  be  condemned. 

In  cases  where  the  patient  is  very  neurotic,  throwing 
herself  about  and  complaining  of  the  greatest  pain,  there 
being  no  sickness  and  an  examination  showing  the  tempera- 
ture and  pulse  to  be  normal  and  distension  absent,  one- 
third  of  a  grain  of  morphia  is  of  the  greatest  possible  value, 
and  will  quiet  her  at  once. 

In  appraising  the  significance  of  pain  after  an  abdominal 
operation,  its  nature  and  the  character  of  the  patient 
must  both  be  taken  into  account.  Where  within  the  first 
twenty-four  hours  the  pain  is  out  of  proportion  to  these 
and  is  accompanied  by  undue  rapidity  of  the  pulse,  some 
disaster  at  the  operation-site  is  to  be  suspected,  such  as 
recurrent  haemorrhage,  which  is  always  associated  with 
severe  pain,  or  the  escape  of  intestinal  contents  through 
an  unnoticed  perforation  of  the  bowel. 

If  the  pain  appears  after  twenty-four  hours,  it  is 
probably  due  to  flatulence,  peritonitis,  or  obstruction,  and 
its  treatment  will  be  discussed  at  pp.  586,  598,  606. 

INSOMNIA 

After  the  first  twenty-four  hours  a  patient  who  is  doing 
well  should  sleep,  at  first  in  short  snatches  and  subse- 
quently for  longer  periods. 


592  GYNECOLOGICAL  SURGERY 

Persistent  insomnia  is  of  bad  import.  Where  peri- 
tonitis, intestinal  obstruction,  or  similar  causes  of  pain 
are  present,  sleep  is  impossible.  In  the  absence  of  pain, 
insomnia  is  seen  in  highly  nervous  patients,  especially  when 
exposed  to  the  necessary  disturbances  that  occur  in  a 
hospital  ward.  It  is  also  seen,  of  course,  as  a  precursor 
of  postoperative  insanity.  Most  characteristically  of  all, 
however,  it  occurs  in  conditions  of  toxic  absorption,  as,  for 
instance,  a  subacute  inflammation  round  the  ligatures  at 
the  operation-site.  In  such  cases,  also,  sleep,  though  not 
absent,  may  be  rendered  distressing  by  nightmare-like 
dreams.  Such  occurrences  are  most  suggestive  of  some- 
thing amiss  in  the  operation-area. 

As  regards  treatment,  morphia  is  often  not  satisfactory, 
but  is  to  be  tried  when  pain  is  present.  In  the  absence 
of  pain,  trianol,  veronal,  sulphonal,  and  bromidia  are  the 
best  drugs.  Bromidia,  in  particular,  has  proved  useful  in 
our  hands. 

SHOCK   AND   HEMORRHAGE 

We  consider  these  two  formidable  complications  to- 
gether because  the  distinction  between  them  forms  the 
most  important  problem  in  all  the  after-treatment  of 
abdominal  sections.  Shock  is  often  a  post-haemorrhagic 
condition  following  a  severe  loss  of  blood  during  a  pro- 
longed operation  ;  these  are  the  cases  so  difficult  to  dis- 
tinguish from  postoperative  haemorrhage.  At  other  times 
it  is  a  condition  of  true  nervous  shock,  such  as  follows 
upon  a  blow  in  the  abdomen.  Lastly,  both  causes  may  be 
in  operation  at  the  same  time.  It  is  necessary  that  post- 
operative haemorrhage  should  be  distinguished  from  shock, 
because  the  treatment  of  the  two  conditions  is  essentially 
different. 

With  respect  to  the  blood  lost  during  an  operation,  we 
have  made  a  very  careful  investigation  in  123  cases  to 
ascertain  its  amount.  A  separate  tin  of  swabs  was  kept 
for  each  patient,  and  a  few  hours  after  this  had  been  ste- 


POSTOPERATIVE  COMPLICATIONS        593 

rilized  it  was  weighed.  At  the  conclusion  of  the  operation 
the  tin  with  the  unused  swabs  was  weighed,  the  difference 
in  weight  between  this  and  that  before  the  tin  was  opened 
indicating  the  weight  of  the  swabs  removed  from  the  tin 
before  they  were  used.  The  used  swabs  were  then  weighed, 
and  the  difference  between  this  weight  and  that  estimated 
for  the  unused  swabs  removed  from  the  tin  gave  us  the 
weight  of  blood  lost  at  the  operation.  We  always  use  dry 
swabs.  The  weight  lost  by  evaporation  from  the  swabs, 
even  after  many  hours,  was  negligible.  One  fluid  ounce  of 
blood  weighs  one  ounce  avoirdupois.  The  following  table 
shows  the  maximum,  minimum,  and  average  loss  of  blood 
in  some  of  the  principal  gynaecological  operations : — - 


Number 

Maximum 

Minimum 

A verage 

Operation. 

of 

amount 

amount 

amount 

cases. 

lost. 

lost. 

lost. 

Total   abdominal  hyster- 

ectomy 

9 

15  oz. 

7  oz. 

II \  oz. 

Subtotal  abdominal  hys- 

terectomy . 

31 

59   „ 

2    ,, 

II 

Abdominal     hystero-vag- 

inectomy    . 

23 

39   „ 

15    .. 

29    „ 

Ovariotomy  . 

19 

9   „ 

1    ,, 

5      .. 

Salpingo-oophorectomy   . 

15 

23    .. 

1    ,, 

8      „ 

Intraperitoneal     shorten- 

ing of  the  round  liga- 

ments 

12 

5    .. 

1    ,, 

3      „ 

Ventro-suspension 

14 

4   .. 

1    ,, 

2i 
^2      •> 

The  largest  quantity  of  blood  lost,  59  oz.,  was  in  a  very 
difficult  case  of  hysterectomy  for  a  cervical  fibroid  which 
weighed  nearly  26  lb.  Omitting  this  case  the  average 
amount  lost  in  30  subtotal  hysterectomies  was  9  oz. 

Dullness  in  the  iliac  fossa  is  a  fallacious  sign  of  haemor- 
rhage, for  the  bowels  float  up  against  the  parietes,  while 
the  colour  of  the  blood  oozing  through  a  gauze  drain  is 
always  pale  because  the  corpuscles  become  entangled  in 
the  meshes  of  the  gauze  and  it  is  principally  serum  which 

2M 


594 


GYNECOLOGICAL  SURGERY 


escapes.  The  fact,  therefore,  that  the  fluid  which  is  escap- 
ing is  pale  in  colour  should  not  lead  the  observer  to  think 
that  haemorrhage  is  absent.  The  necessity  for  a  correct 
diagnosis  between  shock  and  haemorrhage  is  of  vital  import- 
ance, and  it  will  be  better,  therefore,  to  set  out  in  parallel 
columns  the  signs  and  symptoms  of  the  two  conditions. 

Shock 
Signs  date  from  the  operation 
Signs  tend  to  get  better 
Face  may  be  blanched 


Skin  is  cold  and  damp 

Pulse  feeble,  fast  or  slow,  but  the 
cord  of  the  radial  artery  can  be 
felt 

A  blush  can  be  squeezed  into  the 
finger-tips 

The  superficial  veins  are  full  of 
blood,  especially  noted  when 
the  veins  are  exposed  for  in- 
fusion 

Patient  is  quiet,  lying  on  her  back 

The  longer  the  operation  and  the 
more  severe  its  nature,  the  more 
likely  is  shock  to  supervene 

Abdominal  pain  absent 

Patient  is  listless,  apathetic,  and 
takes  no  interest  in  her  sur- 
roundings 

Respirations  are  quick  and 
shallow 

Temperature  may  be  subnormal 

Faintness  not  commonly  com- 
plained of 

Brandy  enemata  improve  shock 


HEMORRHAGE 

Signs  develop  after  the  operation 

Signs  tend  to  get  worse 

Face  and  lips  are  markedly 
blanched 

Skin  is  cold  and  damp 

Pulse  feeble,  nearly  always  fast, 
and  the  cord  of  the  artery 
cannot  be  felt 

A  blush  cannot  be  squeezed  into 

the  finger-tips 
The    superficial    veins    are    col- 
lapsed 


Patient  is  very  restless 
Duration  and  severity  of  the  ope- 
ration are  of  no  significance 

Severe  abdominal  pain 
Patient  is  anxious,  alert,  and  per- 
haps fearful  of  death 

Respirations  are  laboured,  deep, 
and  gasping 

Temperature  commonly  sub- 
normal 

Faintness  complained  of  in  all 
cases,  and  often  a  feeling  of 
sinking  through  the  bed 

Brandy  enemata  increase  hae- 
morrhage 


In  certain  cases  where  the  haemorrhage  takes  the  form 
of  a  slow  continuous  oozing,  many  of  the  classical  symptoms 
may  be   modified  ;     thus,   we  have   seen  several   cases   of 


POSTOPERATIVE   COMPLICATIONS        595 

severe  intraperitoneal  bleeding  where  the  temperature  was 
well  above  normal,  up  to  ioo°  F.  and  even  more,  and 
others  in  which  restlessness  and  air-hunger  were  quite 
absent.     Occasionally,  also,  the  pulse-rate  may  be  low. 

7.  Treatment. — If  shock  be  diagnosed,  the  foot  of  the  bed 
should  be  raised  and  an  ounce  of  brandy  per  rectum  given 
at  once,  together  with  10  ounces  of  saline  solution  at  a 
temperature  of  1020  F.,  and  repeated  every  two  or  three 
hours.  A  hypodermic  injection  of  5  minims  of  strychnine 
is  also  indicated,  and  may  be  repeated  as  often  as  is 
considered  necessary.  The  patient  should  be  wrapped  in 
blankets,  and  hot-water  bottles  used  to  maintain  heat. 
If  the  condition  is  serious  and  the  patient  does  not  react  to 
these  measures,  two  or  three  pints  of  saline  solution  should 
be  run  into  the  veins,  or  continuous  saline  infusion 
can  be  administered.  The  administration  of  adrenalin 
and  pituitary  extract  has  been  much  lauded  in  shock. 
Our  experience  is  against  the  use  of  vaso-constrictants. 
They  have  been  advised  theoretically  on  the  assumption  that 
by  producing  arterial  contraction  the  blood-pressure  will 
be  beneficially  raised.  We  are,  however,  of  opinion  that 
where  the  heart  is  already  beating  so  feebly  as  to  be  in 
momentary  danger  of  stopping  altogether,  the  handicap 
of  increased  resistance  frequently  precipitates  that  catas- 
trophe. The  most  useful  drugs  in  cases  of  shock  are  alcohol 
and  strychnine.  Digitalin  should  not  be  employed ;  it 
raises  the  blood-pressure  and  has  no  beneficial  action  on 
the  heart  in  these  cases,  and  in  our  experience  makes 
matters  worse. 

If  hemorrhage,  however,  be  diagnosed,  there  is  but  one 
thing  to  do,  and  that  is  to  secure  the  bleeding  vessel.  We 
are  most  strongly  of  opinion  that  infusion  should  never  be 
practised  until  the  bleeding-point  has  been  secured,  no 
matter  how  tempting  the  treatment  appears  to  be.  Such 
treatment  is  more  futile  than  trying  to  fill  a  bottle  with  a  hole 
in  its  bottom,  and  it  prevents  Nature  from  checking  the 
haemorrhage  by  her  own  method,  namely,  by  the  formation 


596  GYNECOLOGICAL  SURGERY 

of  a  clot  in  the  bleeding  vessel  when,  by  reason  of  the 
haemorrhage,  the  circulation  through  it  is  sufficiently  feeble 
to  allow  of  thrombosis  taking  place.  That  this  is  so  is 
proved  by  the  fact  that  where,  in  these  cases,  death  has 
followed  venous  infusion,  the  peritoneal  cavity  is  found 
to  be  filled  with  a  mixture  of  blood  and  saline  solu- 
tion ;  the  vessels,  in  short,  have  been  flushed  out  with 
salt-and-water.  It  is  important  to  remember  that  when 
the  wound  is  reopened  no  bleeding-point  may  be  found  if 
the  haemorrhage  has  been  severe,  the  bleeding  having 
temporarily  stopped  of  its  own  accord.  In  this  case  a 
careful  search  must  be  made  for  a  slipped  ligature  at  the 
various  points  where  ligatures  have  been  applied,  an 
assistant  meanwhile  administering  a  saline  venous  infusion. 
As  the  blood-pressure  rises,  the  bleeding-point  will  probably 
become  evident.  Very  little  or  no  anaesthetic  is  required 
for  these  manipulations,  and  it  is  marvellous  how  nearly 
moribund  a  person  may  be  and  yet  recover  after  a  saline 
infusion.  Instead  of  venous  infusion  a  pint  of  warm  saline 
solution  may  be  injected  under  each  breast  by  means  of  an 
aspirating  trocar,  a  tube,  and  a  glass  funnel ;  or  large  rectal 
injections  of  the  same  fluid  may  be  given  (see  p.  578).  For 
our  part,  as  mentioned  earlier,  we  prefer  venous  infusion. 

In  both  haemorrhage  and  shock  the  head  is  to  be  kept 
as  the  lowest  part  of  the  body  and  every  effort  made  to 
maintain  warmth. 

Anxious  uncertainty  will  often  be  the  lot  of  the  watcher 
in  these  cases,  but  it  is  better  to  reopen  a  wound  and  make 
sure  that  the  condition  is  only  due  to  shock  than  to  infuse 
a  patient  who  has  a  vessel  patent.  Here  we  would  again 
emphasize  the  extreme  importance  of  frequent  and  careful 
observation  of  the  pulse-rate  after  abdominal  operations. 
We  have  known  cases  where  the  diagnosis  of  haemorrhage 
and  its  successful  treatment  have  been  solely  founded 
upon  a  rapid  and  otherwise  unexplainable  rise  in  the  pulse- 
rate,  and  there  is  nothing  in  which  a  house-surgeon  may 
take  such  legitimate  pride  as  the  knowledge  that  his  careful 


POSTOPERATIVE   COMPLICATIONS        597 

observation    and    accuracy    of    judgment    have    been    the 
means  of  saving  a  patient's  life. 

REMOTE   SHOCK 

We  have  applied  this  term,  for  want  of  a  better,  to  a 
condition  which  will  be  familiar  to  all  who  have  experience 
of  abdomino-pelvic  surgery.  The  patient  is  elderly,  she  is 
enfeebled,  and  she  is  the  subject  of  cardio-vascular  degenera- 
tion. The  operation  has  been  severe,  and  usually  accom- 
panied by  considerable  loss  of  blood ;  shock  immediate,  and 
presenting  the  symptoms  just  described,  has  followed  on  it ; 
and  the  patient  under  appropriate  treatment  has  rallied. 
On  the  morning  following  the  operation  she  presents  a  very 
typical  picture.  The  pulse  is  fast,  strong,  and  throbbing, 
the  eyes  are  glistening,  and  the  mental  condition  is  very 
active.  The  patient  expresses  herself  as  feeling  "  quite 
well,"  "  never  better,"  and  so  forth.  All  these  symptoms 
become  accentuated  as  the  day  goes  by,  and  there  is  great 
restlessness  and  a  total  absence  of  sleep.  On  the  next 
day  the  pulse  is  still  faster  but  softer  and  more  running, 
and  the  apex-beat  of  the  heart  will  be  found  to  have  moved 
outwards  beyond  the  nipple-line.  Mental  excitement 
remains,  but  the  patient  has  a  difficulty  in  recognizing 
those  about  her  and  she  rambles  in  her  speech.  There  is 
a  progressive  loss  of  strength,  and  the  skin  becomes  cold, 
the  pulse  imperceptible,  and  the  respirations  fast.  Death 
ensues  in  from  two  to  four  days  after  operation.  Stimu- 
lating treatment  is  indicated,  but  in  our  experience  nearly 
all  the  cases  in  which  these  symptoms  have  typically 
developed  have  ended  fatally. 

Post-mortem  examination  discloses  no  local  abdominal 
cause  for  death,  the  site  of  the  operation,  the  intestine,  and 
the  peritoneum  being  satisfactory ;  but  the  heart  in  all  the 
cases  is  fatty  and  dilated,  and  it  is  to  the  acute  dilatation 
and  failure  of  this  organ  that  the  fatal  termination  must 
be  ascribed. 


CHAPTER    XXXV 
POSTOPERATIVE    COMPLICATIONS   (Continued) 

PERITONITIS 

Causes. — Septic    peritonitis    is    due    to    infection    of    the 
peritoneum  from — 

(i)  Some    instrument,  ligature,  suture,   swab   or  towel. 

(2)  The  hands  or  breath  of  the  operator  or  of  his 
assistants. 

(3)  Pus  or  faecal  matter  which  has  escaped  during  the 
process  of  the  operation,  as,  for  instance,  when  an  ovarian 
cyst  or  pyo-salpinx  is  being  removed  or  adherent  intestines 
are  being  separated. 

(4)  The  skin  of  the  patient. 

(5)  The  patient's  vagina. 

(6)  An  effusion  of  blood.  It  has  been  shown  by  Sargent 
and  Dudgeon  that  the  presence  of  blood  in  the  peritoneal 
cavity  is  shortly  followed  by  the  appearance  of  a  staphy- 
lococcus, and  it  is  a  matter  of  common  experience  that 
haematoceles  are  soon  followed  by  signs  of  local  peri- 
tonitis. 

(7)  Auto-infection  of  damaged  tissue.  It  is  obvious 
that  the  more  the  patient's  tissues  are  bruised  by  rough 
handling,  the  greater  the  liability  to  infection.  Further, 
there  are  certain  conditions  of  tissue-damage  that  peculiarly 
favour  bacterial  activity.  It  is  a  remarkable  fact  that 
areas  of  complete  vascular  stasis  (white  infarction) ,  whether 
produced  by  an  embolus  or  due  to  an  occluding  ligature, 
are  not  associated  with  inflammatory  phenomena,  whereas 
those  of  partial  vascular  stasis,  and  especially  of  venous 
stasis  such  as  is  found  in  the  tissue  distal  to  the  twist  of  an 
ovarian  pedicle  or  the  constriction  at  the  neck  of  a  hernial 

598 


POSTOPERATIVE  COMPLICATIONS        599 

sac,  rapidly  become  the  seat  of  an  intense  bacterial  invasion. 
The  absence  of  any  symptoms  following  the  application  of 
a  surgical  ligature  to  a  piece  of  omentum,  as  compared 
with  the  violent  results  when  the  same  tissue  becomes 
strangulated  in  a  hernial  sac,  may  be  cited  in  support  of 
the  above  statements.  Tissues  so  damaged,  and  lying  in 
close  proximity  to  the  bacteria-laden  intestine,  readily 
become  the  seat  of   auto-infection   therefrom  (see  p.  41). 

Septic  peritonitis  is  most  commonly  due  to  some  flaw 
in  the  aseptic  technique.  The  greater  the  care  that  is  taken 
with  the  preparation  of  the  patient,  instruments,  swabs, 
ligatures,  and  the  hands  of  the  surgeon  and  nurses,  the 
fewer  will  be  the  number  of  cases  occurring  in  the  surgeon's 
practice.  As  a  proof  of  this,  one  has  only  to  examine 
the  statistics  of  different  hospitals,  or  of  different  surgeons 
in  the  same  hospital.  Granted  a  certain  amount  of  opera- 
tive ability,  a  surgeon's  results  will  depend  not  so  much 
on  the  difficulties  of  the  case  or  the  rapidity  of  his  mani- 
pulations as  on  careful  and  minute  attention  to  secure  a 
perfect  asepsis,  or  an  asepsis  as  nearly  perfect  as  may  be. 
Wherever  the  greatest  precautions  are  taken  to  keep  the 
operation  and  its  field  aseptic,  there  will  the  best  results 
be  found. 

Further,  from  a  study  of  the  causes  of  peritonitis,  it 
is  evident  that  the  more  perfect  the  haemostasis  the  less 
likelihood  will  there  be  of  peritoneal  infection,  other  things 
being  equal.  Thus,  the  surgeon  who,  to  attain  rapidity, 
is  content  to  take  the  chance  of  capillary  oozing  occurring 
after  he  has  closed  the  wound,  may  be  chagrined  to  find 
that  his  case  does  not  run  the  same  apyrexial  course  as 
that  of  a  colleague  at  whose  slow  and  laborious  workman- 
ship he  is  apt  to  scoff. 

Lastly,  from  our  remarks  on  the  auto-infection  of 
damaged  tissue,  it  will  be  seen  how  necessary  it  is  for  the 
surgeon  to  handle  as  lightly  as  possible  the  tissues  with 
which  he  is  dealing,  and  to  remember  when  applying 
ligatures  that  nothing  is  so   likely  to  become  infected  as 


6oo  GYNECOLOGICAL  SURGERY 

a   mass   of    tissue   whose   vascular   mechanism   is    gravely 
interfered  with  but  not  entirely  occluded. 

General  Peritonitis 

Symptoms  and  signs.  —  The  first  symptoms  of  peri- 
tonitis appear,  as  a  rule,  about  the  third  day.  In  cases 
infected  before  the  operation,  they  may  appear  earlier  ; 
in  fact,  the  patient  may  never  have  been  quite  satisfac- 
tory. Lastly,  and  more  rarely,  this  complication  may  only 
declare  itself  towards  the  end  of  the  first  week. 

Pulse.— Instead  of  the  pulse-rate  falling,  as  it  should 
do,  and  usually  does,  within  twelve  hours  of  the  operation, 
it  gradually  increases  in  frequency  to  120  and  upwards. 
It  is  at  first  quick,  small,  and  hard,  but  as  the  fatal 
termination  draws  nigh  its  strength  decreases,  and  at  the 
last  it  cannot  be  felt. 

Temperature. — -This,  as  a  rule,  is  above  normal  from 
the  first,  and  continues  to  rise  until  it  reaches  1040  F.,  or 
even  higher.  A  rapidly  rising  temperature  on  the  second  day 
is  a  symptom  of  serious  import.  The  temperature,  how- 
ever, is  not  so  good  a  guide  as  some  of  the  other  signs,  for 
even  in  very  acute  cases  the  rise  may  not  be  marked,  and  in 
some  of  the  worst  cases,  especially  when  of  a  suppurating 
character,  the  temperature  may  be  subnormal. 

Vomiting. — See  p.  585. 

Distension. — See  p.  589.  Exceptionally  there  may  be 
no  distension,  the  belly  being  retracted  and  hard. 

Pain.— Abdominal  pain  is  one  of  the  first  symptoms 
complained  of,  and  may  be  frightful  in  its  intensity,  though 
rarely,  in  some  of  the  worst  cases,  and  especially  those 
associated  with  a  purulent  effusion,  pain  is  absent.  We 
have  noted  as  a  very  bad  prognosis  the  complaint  of  pain 
felt  under  the  ribs  and  through  to  the  back. 

Respiration. — The  breathing  is  purely  thoracic  and  very 
rapid ;  and  it  may  here  be  noted  that  while  a  rapid  pulse 
following  abdominal  section  is  a  bad  sign,  its  conjunction 
with  rapid  respiration  is  peculiarly  ominous. 


POSTOPERATIVE  COMPLICATIONS        601 

Abdominal  tenderness. — As  a  rule,  abdominal  tender- 
ness is  very  marked,  and  universal.  The  patient  cannot 
bear  the  least  pressure  on  the  abdomen.  In  those  rarer 
cases  where  the  temperature  is  subnormal,  the  distension 
not  marked,  and  the  pain  but  slight,  the  abdominal  tender- 
ness may  be  absent. 

Defalcation. — -The  bowels  are  very  inert,  neither  flatus 
nor  faeces  passing,  and  aperients  or  enemata  having  no 
effect. 

Micturition.  ■ — ■  Pain  on  micturition  is  present,  and  is 
due  to  the  movement  of  the  inflamed  peritoneum  covering 
the  bladder  as  this  organ  contracts.  The  dread  of  this 
pain  is  such  that  at  times  retention  results. 

General  signs.  —  The  patient  is  restless,  she  has  an 
anxious  expression,  her. face  becomes  drawn  and  her  com- 
plexion grey ;  the  features  are  pinched  and  shrunken, 
her  tongue  is  dry  and  brown,  the  body  is  bathed  in  a  cold 
perspiration,  the  extremities  are  cold ;  mental  activity  may 
be  maintained  almost  to  the  last,  but  occasionally  delirium 
and  coma  end  the  scene. 

The  duration  of  the  symptoms  from  start  to  finish  is 
rarely  over  three  days. 

Treatment.  — ■  General  peritonitis  is  an  extremely  fatal 
disease.  That,  however,  is  no  reason  why  all  treatment 
should  be  abandoned  when  it  is  diagnosed,  since  there  is 
always  the  possibility  of  the  condition  being  due  to  a 
localized  infection  with  severe  general  symptoms,  and  on 
occasions  patients  recover  even  after  general  peritonitis. 

The  chief  point  is  to  "  keep  the  patient  going  "  as  long 
as  possible  in  the  hope  that  she  may  be  able  to  withstand 
the  infection.  There  are  five  lines  of  treatment  having 
this  object  in  view.     They  are — 

i.  Injection  of  antitoxic  serum. 

2.  Vaccine  treatment. 

3.  Injection  of  saline  solution. 

4.  Multiple  drainage  and  posture. 

5.  Stimulants,  etc. 


602  GYNAECOLOGICAL  SURGERY 

1.  Injection  of  antitoxic  serum. — The  most  commonly 
found  organisms  in  general  peritonitis  are  the  colon  bacillus 
and  streptococci.  In  a  small  proportion  of  cases  staphy- 
lococci are  present.  It  is  impossible,  in  most  cases  of 
peritonitis,  to  be  sure  as  to  the  nature  of  the  infecting 
organism,  but  in  view  of  these  general  findings  it  is  advis- 
able to  administer  an  anti-colon  and  an  anti-streptococcic 
serum  together  until  definite  bacteriological  indications  are 
obtained.  The  results  of  this  treatment  are  disappointing, 
but  it  does  no  harm  if  it  does  no  good.  A  dose  of  25  c.c. 
of  each  serum  should  be  injected  in  the  skin  over  the  side 
of  the  chest,  and  should  be  repeated  in  six  hours,  and  again 
six  hours  after  that.  If  no  result  has  then  been  produced, 
it  is  useless  to  continue  the  injections.  If  the  patient 
reacts  favourably,  10  c.c.  of  each  serum  should  be  given 
twice  a  day. 

If  serum  is  going  to  be  used  at  all,  it  should  be  ex- 
hibited directly  the  surgeon  forms  the  opinion  that  the 
case  is  one  of  general  infection,  and  not,  as  generally 
happens,  as  a  last  resort  when  the  case  is  practically 
hopeless. 

2.  Vaccines. — When  the  causative  organism  is  known, 
a  vaccine  may  be  prepared  and  administered.  To  obtain 
a  vaccine  in  this  way  takes  48 — 72  hours.  Stock  vaccines 
are  now  sold  by  all  the  leading  druggists  which  can 
be  used  after  the  bacteriological  diagnosis  has  been 
made,  and  pending  the  obtaining  of  the  special  vaccine. 
Since,  however,  the  patient  is  already  absorbing  over- 
whelming quantities  of  bacterial  toxin,  the  logic  of  intro- 
ducing a  minute  quantity  of  the  material  with  a  view  to 
cure  appears  questionable. 

3.  Continuous  injection  of  saline  solution. — This  method 
consists  in  injecting  large  quantities  of  saline  solution  into 
the  cellular  tissue.  The  technique  is  fully  described  at 
p.  579.     The  rationale  of  the  treatment  is  as  follows  : — 

(1)  The  body  is  short  of  water  because  of  the  incessant 
vomiting  and  inability  to  drink.     In  the  absence  of  sum- 


POSTOPERATIVE  COMPLICATIONS        603 

cient  water  the  leucocytes  are  unable  to  resist  the  infecting 
micro-organisms . 

(2)  If  the  blood  is  deficient  in  water  the  infected  peri- 
toneal exudation  tends  to  pass  into  the  blood-current. 
If  an  excess  of  water  is  introduced  into  the  blood  the 
process  is  reversed. 

(3)  The  saline  solution  by  diluting  the  toxins  renders 
them  less  harmful. 

We  have  seen  marked  benefit  result  from  this  treat- 
ment, but  in  some  cases  there  is  difficulty  in  maintaining 
the  flow  of  the  fluid.* 

4.  Multiple  drainage  and  posture.  —  The  value  of 
multiple  drainage  is  very  great.  Unfortunately,  in  post- 
operative general  peritonitis  the  patient  is  so  bad  by  the 
time  the  diagnosis  is  made  that  the  surgeon  is  chary  of 
any  further  operative  treatment,  and  the  patient  is  unable 
to  bear  even  the  necessary  anaesthetic ;  but  where  the 
condition  is  discovered  at  the  operation  this  treatment 
should  be  adopted.  Incisions  should  be  made  over  and 
drainage-tubes  inserted  into  the  pelvis  in  the  middle  line, 
both  iliac  fossae,  and  both  lumbar  pouches.  Such  measures 
must  be  aided  by  maintaining  the  patient  in  the  raised 
posture  or,  best  of  all,  in  Fowler's  position  (i.e.  a  reversed 
Trendelenburg)  if  the  necessary  apparatus  is  at  hand. 

5.  Stimulants. — Apart  from  the  four  methods  of  treat- 
ment already  dealt  with,  the  surgeon  can  only  combat 
heart-failure  by  brandy  and  strychnine,  and  treat  com- 
plications such  as  vomiting  and  distension  by  the  methods 
indicated  at  pp.  583-90.  When  this  treatment  has 
failed  and  death  approaches,  injections  of  morphia  should 
be  given  in  such  doses  as  to  establish  euthanasia. 

Local  Peritonitis 

Symptoms  and  signs. — As  a  rule,  for  some  days  the 
patient  appears  to  be  progressing  satisfactorily.     Then  the 

*  The  credit  of  introducing  this  treatment  to  English  surgeons  is  due  to 
the  late  Harold  Barnard. 


6o4  GYNECOLOGICAL   SURGERY 

pulse-rate  and  temperature  commence  to  rise,  but  in  neither 
case  to  any  extreme,  the  pulse  being  generally  under  120 
and  the  temperature  fluctuating  between  ioo°  F.  and 
1030  F. ;  the  abdomen  is  slightly  distended,  and  there  are 
pain  and  tenderness,  most  often  of  a  localized  character. 
In  other  cases  the  general  symptoms  may  be  more  marked : 
the  temperature  is  higher,  the  pulse-rate  quicker,  the 
tongue  may  become  dry  and  brown,  vomiting  may  be 
troublesome,  pain  may  be  intense  ;  and  if  together  with 
all  these  the  local  disease  cannot  be  distinguished,  the  case 
may  be  mistaken  for  one  of  general  peritonitis.  In  local 
peritonitis,  however,  a  tumour  sooner  or  later  appears,  con- 
sisting of  adherent  and  thickened  omentum,  bowel,  and 
peritoneal  exudate. 

Diagnosis. — On  any  symptom  of  sepsis  appearing,  the 
surgeon  should  carefully  examine  the  patient  to  ascertain 
if  there  is  a  local  cause. 

The  abdominal  wound  should  be  inspected,  the  iliac 
regions  palpated,  and  a  vaginal  examination  made.  If 
local  peritonitis  is  present,  a  hard  and  very  tender  swelling 
may  be  found  in  the  region  of  the  pedicle,  or  an  inflam- 
matory mass  can  be  made  out  filling  up  the  pelvis  and 
extending  towards  the  abdominal  wound. 

The  symptoms  are  often  those  of  partial  intestinal  ob- 
struction with  vomiting,  fever,  and  wasting.  These  cases 
usually  terminate  by  a  copious  discharge  of  pus,  often 
stinking,  from  the  lower  end  of  the  abdominal  wound, 
followed  by  instant  relief. 

Fetor  is  no  indication  of  a  communication  with  the 
bowel  unless  it  is  accompanied  by  gas  and  faecal  matter, 
but  the  establishment  of  a  faecal  fistula  is  commonly  pre- 
ceded by  these  symptoms  of  local  suppurative  peritonitis. 
The  possibility  of  this  complication  is  the  strongest  argu- 
ment in  favour  of  draining  the  operation-site  by  a  small 
tube  in  all  those  cases  in  which  the  asepticity  of  that 
site  cannot,  by  reason  of  the  previous  condition,  be 
ensured. 


POSTOPERATIVE  COMPLICATIONS       605 

The  tube,  which  should  be  removed  in  forty-eight  hours, 
establishes  a  track  along  which  the  pus,  if  it  forms,  can 
readily  make  its  way  to  the  surface. 

Results.  —  As  a  rule,  cases  of  localized  postoperative 
peritonitis  recover  in  the  end,  although  convalescence  may 
be  delayed  several  weeks.  In  a  few  days  adhesions  are 
formed  round  the  infected  area  which  prevent  any  general 
absorption,  and  a  certain  number  of  cases  recover  without 
suppuration.  Rarely,  a  general  septic  peritonitis  starts 
from  the  local  focus. 

Treatment. — If  pus  is  diagnosed  it  must  be  evacuated. 
If  the  swelling  presents  in  the  neighbourhood  of  the  wound, 
this  should  be  reopened.  If  there  is  a  marked  swelling  in 
Douglas's  pouch,  of  a  fluid  nature,  an  incision  should  be 
made  into  it  from  the  vagina,  and  after  it  is  evacuated  the 
cavity  should  be  drained  with  a  tube.  If  an  abscess  appears 
in  the  iliac  region  it  should  be  opened  there.  Any  further 
complications  should  be  treated  as  they  arise.  For  the 
pain,  hot  fomentations  with  glycerine  and  belladonna  or 
laudanum  may  be  applied  to  the  abdomen  and  morphia 
may  be  given  internally,  whilst  vaginal  injections  of  some 
antiseptic  solution  at  no0  F.  often  give  much  relief  and 
seem  at  times  to  cause  absorption.  If  the  heart  is  weak 
it  should  be  treated  with  strychnine  and  brandy. 

The  bowels  must  be  regulated  with  enemata,  and  the 
patient  fed  per  rectum  if  the  vomiting  and  distension  are 
marked. 

PELVIC    CELLULITIS 

Inflammation  of  the  cellular  tissue  of  the  pelvis,  and 
more  especially  that  of  the  broad  ligament,  may  follow  a 
dilatation  of  the  cervix,  where  the  cervical  tissue  has  been 
lacerated  ;  a  curetting  of  the  uterus  ;  or  some  operation 
involving  the  broad  ligament.  For  instance,  infection  may 
spread  from  a  septic  stump  after  the, removal  of  a  pyo- 
salpinx,  or  subtotal  hysterectomy ;  or  after  the  enucleation 
of   a    broad-ligament   tumour   a  vessel   may   ooze,  causing 


606  GYNECOLOGICAL  SURGERY 

a  hematoma,  which  later  may  become  infected  from  the 
bowel.  The  patient  complains  of  fever,  headache,  nausea, 
thirst,  anorexia,  and  of  pain  in  one  or  other  side  of  the 
lower  abdomen.  An  examination  will  show  her  pulse  to 
be  quickened,  her  temperature  to  be  raised,  the  lower 
abdomen  on  the  affected  side  markedly  tender,  and  per 
vaginam  a  tender  swelling  can  be  felt  in  one  or  other  lateral 
fornix,  somewhat  depressing  it.  The  uterus,  if  present,  will 
be  fixed  and  pushed  over  somewhat  towards  the  opposite 
side.  As  a  rule,  after  a  few  days  the  condition  subsides, 
and  the  patient  rapidly  recovers.  Much  more  rarely  it 
becomes  worse,  pus  forms,  and  this,  if  not  evacuated, 
points  in  one  of  several  places,  among  which  may  be  men- 
tioned the '  abdomen  just  above  the  groin,  the  buttock 
through  the  sciatic  foramen,  the  vagina,  the  bladder,  or 
the  rectum. 

Treatment. — Before  suppuration  has  taken  place,  the 
general  condition  of  the  patient  must  be  treated  with  quin- 
ine and  sedatives  (if  the  pain  warrants  their  exhibition), 
the  local  disease  with  vaginal  douches  of  a  temperature  of 
no0  F.  and  abdominal  fomentations.  If  pus  forms,  it 
should  be  let  out  by  an  incision  before  it  has  time  to  point, 
the  best  way  to  get  at  it  being  through  the  vaginal  fornix. 
The  swelling  should  be  stabbed  with  a  scalpel,  after  which 
a  pair  of  pressure-forceps  is  inserted,  their  points  separated 
and  withdrawn  in  this  position,  and  a  drainage-tube  passed 
into  the  opening— and  kept  in  position,  if  necessary,  by 
suturing  it  to  the  cut  edge  of  the  vagina.  Hot  douches 
should  then  be  given  twice  daily. 

INTESTINAL    OBSTRUCTION 

Intestinal  obstruction  is  due  either  to  organic  occlusion 
of  the  lumen  of  the  intestine  in  some  part  of  its  course,  or 
to  a  complete  paralysis  of  the  intestinal  wall  affecting 
its  whole  length  or  limited  to  some  particular  segment. 
The  former,  as  the  commoner  variety,  will  be  first  con- 
sidered. 


POSTOPERATIVE  COMPLICATIONS       607 

Organic  Obstruction 

This  form  of  obstruction  is  due — 

1.  To  adhesions  of  intestine  to  other  parts. 

2.  To  escape  of  intestine  through  some  orifice. 

3.  To  inclusion  of  intestine  in  a  ligature. 

4.  To  strangulation  by  bands. 

1.  Adhesions  of  intestine  to  other  parts. — The  intes- 
tine may  become  adherent  to  the  pedicle  left  after  the 
removal  of  an  ovarian  cyst  or  a  diseased  tube,  to  the  stump 
or  suture-line  after  a  subtotal  hysterectomy,  to  the  suture- 
line  after  total  hysterectomy,  to  another  piece  of  intestine, 
to  the  back  of  the  uterus,  the  broad  ligament,  or  the  floor 
of  the  pelvis  rough  from  adhesions,  especially  after  opera- 
tions for  salpingitis,  or  to  the  parietal  wound.  As  a  result 
of  the  adhesion,  the  lumen  of  the  bowel  becomes  narrowed 
and  gradual  obstruction  results. 

2.  Escape  of  intestine  through  some  orifice.  —  The 
intestine  may  slip  through  a  hole  in  the  mesentery,  a  hole 
formed  by  an  adhesion  or  by  another  piece  of  intestine 
becoming  adherent  to  some  other  organ,  the  pelvic  wall  or 
abdominal  parietes. 

Also,  in  cases  where  the  abdominal  wound  has  been 
insecurely  fastened,  or  where  great  straining  and  vomiting 
has  caused  a  stitch  in  the  wound  to  give,  a  knuckle  of 
intestine  has  slipped  through  between  the  cut  edges  of  the 
fascia  and  become  nipped. 

This  accident  has  happened,  too,  during  the  closure 
of  the  abdominal  wound,  a  piece  of  gut  projecting  between 
the  cut  edges  of  the  incision  and  remaining  undetected. 

3.  Inclusion  in  a  ligature.— If  the  operator  is  careless, 
a  piece  of  bowel  can  easily  be  included  in  a  pedicle-ligature. 
In  cases  where  a  tumour  of  the  left  side  has  distended 
the  mesosigmoid,  care  must  specially  be  taken  to  avoid 
including  a  piece  of  the  colon  in  the  ligature  that  secures 
the  ovarian  artery,  for  owing  to  the  very  close  proximity 
of  the  sigmoid  to  the  left  broad  ligament  this  danger  is 


608  GYNAECOLOGICAL  SURGERY 

a  very  definite  one.  It  may,  however,  be  avoided  by 
deliberately  incising  the  peritoneal  frsenum  that  unites  the 
colon  to  the  ligament,  before  applying  the  ligature. 

4.  Strangulation  by  bands.  —  As  a  result  of  inflam- 
matory processes  in  the  abdomen  or  pelvis,  bands  may 
form,  attached  to  different  structures,  and  the  intestine, 
slipping  underneath,  may  become  strangulated.  In  other 
cases  the  omentum  becomes  adherent  in  the  pelvis  and 
exercises  injurious  traction  on  the  transverse  colon.  Where 
the  ovarico-pelvic  ligament  is  thickened  and  shortened  as 
the  result  of  chronic  inflammation,  ligatures  applied  to  it 
may  so  shorten  this  structure  as  to  pull  upon  the  sigmoid 
mesocolon  at  the  brim  of  the  pelvis  and  kink  the  bowel. 
Lastly,  appendices  epiploicae  are  peculiarly  liable  to  contract 
adhesions,  thus  anchoring  a  loop  of  the  colon  in  the  pelvis 
by  a  narrow  pedicle  around  which  the  bowel  may  rotate 
and  strangulate. 

In  themselves  the  conditions  mentioned  are  compar- 
atively rarely  the  determining  cause  of  the  obstruction  ; 
it  is  the  supervention  on  them  of  flatulent  distension 
which  as  a  rule  actually  produces  the  kink. 

Onset  and  signs. — -These  may  supervene  at  any  time 
from  the  second  day  onwards.  In  most  cases  they  declare 
themselves  by  the  end  of  the  week,  but  we  have  known 
instances  in  which  obstruction  was  delayed  for  over  a  year. 
The  time  when  the  obstruction  declares  itself  depends 
entirely  on  the  cause.  If  a  knuckle  of  intestine  is  included 
in  a  pedicle-ligature,  the  symptoms  supervene  early.  Those 
cases  that  occur  after  many  months  are  due  to  contraction 
of  bands.  If  a  piece  of  bowel  becomes  adherent  to  a  stump 
or  pedicle,  it  will  be  eight  or  ten  days,  perhaps,  before 
any  alarming  symptoms  arise. 

Symptoms  and  diagnosis — Intestinal  obstruction  has  to 
be  diagnosed  from  peritonitis  and  paresis  of  the  bowel.  The 
distinction  is  so  important  that  it  is  necessary  to  consider 
it  in  detail  under  the  following  heads  : — 

1.  Pain. — The    pain    of    intestinal    obstruction    is     an 


POSTOPERATIVE  COMPLICATIONS       609 

intermittent  colic  of  great  intensity,  which  is  excited  by 
taking  food  into  the  stomach  or  by  abdominal  palpation. 
When  the  obstruction  is  situated,  as  it  most  often  is,  in 
the  pelvic  colon,  the  patient  when  describing  the  course 
of  the  pain  correctly  indicates  the  surface-marking  of  the 
large  intestines  from  right  to  left.  The  pain  of  peritonitis 
is  continuous,  whilst  in  paresis  of  the  bowel  colicky  pain, 
or  the  sensation  of  intestinal  movement,  is  absent,  though 
the  patient  may  complain  of  a  distressing  feeling  of  dis- 
tension. 

2.  Abdomen. — -The  distension  of  intestinal  obstruction 
is  always  local  to  begin  with,  and,  even  when  general,  is 
more  marked  at  one  spot  ;  thus  in  sigmoid  obstruction 
the  most  striking  tumidity  is  in  the  left  iliac  region,  whilst 
in  that  due  to  adhesion  of  the  intestine  to  the  abdominal 
wound  a  very  characteristic  swelling  can  be  felt  round  this 
area.  The  abdomen  is  rigid,  but  not  markedly  tender, 
but  palpation  may  excite  movements  of  the  bowel,  accom- 
panied by  audible  borborygmi.  When  the  obstruction  has 
become  profound,  the  distension  is  so  great  that  the  skin 
is  shiny. 

In  peritonitis,  on  the  other  hand,  the  distension 
is  general  from  the  first,  there  is  marked  tenderness  and 
rigidity,  but  no  intestinal  movements  can  be  felt  or  heard, 
nor  does  the  distension  become  so  extreme. 

In  paresis  of  the  bowel,  the  abdomen,  though  universally 
distended,  is  not  painful,  and  there  is  a  complete  absence 
of  intestinal  movement. 

3.  Fever. — In  intestinal  obstruction,  fever  as  a  rule  is 
absent,  and  towards  the  close  the  temperature  may  be 
subnormal ;  whereas,  in  peritonitis,  fever  is  commonly 
present,  whilst  in  paresis  of  the  bowel  the  temperature  is 
normal. 

4.  Flatus  and  results  of  enemata. — In  the  early  stages 
of  intestinal  obstruction  some  flatus  is  nearly  always  passed 
with  the  rectal  tube,  but  the  amount  becomes  progressively 
less,    in    spite    of    the    increasing    gaseous    distension.      In 

2    N 


6io  GYNECOLOGICAL  SURGERY 

peritonitis,  flatus  is  not  obtained  by  the  rectal  tube,  whilst 
in  paresis  a  copious  discharge  with  the  tube  is  common 
though  none  is  passed  naturally. 

When  the  site  of  obstruction  is  low  down,  as  it  commonly 
is,  it  may  be  found  impossible  to  introduce  the  rectal  tube 
more  than  a  short  distance,  and  enemata  or  large  wash- 
outs cannot  be  retained.  In  peritonitis  and  paresis  no 
such  obstruction  exists,  and  enemata  are  apt  to  be  retained. 

5.  Vomiting.  — ■  The  vomiting  of  obstruction  is  truly 
spontaneous,  and  quite  irrespective  of  the  introduction  of 
fluid  into  the  stomach.  A  very  characteristic  feature  is 
that  the  patient,  after  retaining  all  that  has  been  given 
her  for  several  hours,  suddenly  and  without  warning  ejects 
a  large  quantity  of  fluid  containing,  undigested,  all  the 
food  she  has  taken.  As  the  case  advances,  the  vomit 
becomes  brown  in  colour,  and  at  last  in  some  instances 
definitely  faecal. 

In  peritonitis,  on  the  other  hand,  the  amount  vomited 
is  less  in  comparison,  and  as  a  rule  immediately  follows 
the  reception  of  food  into  the  stomach.  It  does  not  become 
faecal. 

In  paresis,  vomiting  may  be  absent  at  first,  but  later 
on  it  becomes  copious  in  quantity  and  brown  in  colour. 
In  extreme  cases  it  is  faecal  at  the  close. 

6.  Facies. — In  obstruction  the  aspect  of  the  patient 
is  one  of  acute  distress  during  the  spasms  of  pain,  succeeded 
by  a  period  of  comparative  calm  in  their  interval.  In 
peritonitis  the  patient  wears  a  look  of  constant  agony. 
In  paresis  the  face  is  distressed  in  proportion  to  the  amount 
of  distension,  but  does  not  bear  that  look  of  apprehension 
which  is  seen  in  organic  obstruction. 

Treatment,  i.  Prophylactic. — It  is  impossible  entirely 
to  avoid  the  risk  of  intestinal  obstruction  after  pelvic 
operations,  but  it  may  be  diminished  by  attention  to  the 
following  points  : — 

One  of  the  disadvantages  which  attend  the  use  of 
catgut   for   ligatures   or   sutures   is   the   risk   of    intestinal 


POSTOPERATIVE  COMPLICATIONS        611 

obstruction  owing  to  its  yielding,  or  its  too  rapid  absorption, 
with  the  result  that  oozing  occurs,  or  the  edges  of  a  peri- 
toneal suture-line  gape  and  leave  a  raw  surface.  In  either 
case  the  intestine  is  very  likely  to  contract  adhesions. 
We  remember  three  cases  in  particular  in  which  the  patients 
died  from  this  cause. 

Intestine  and  omentum  are  peculiarly  liable  to  adhere 
to  surfaces  covered  by  a  film  of  blood-clot,  and  it  is  impor- 
tant in  this  regard  to  ensure  as  perfect  an  hsemostasis  as 
possible. 

Inflamed  omentum  is  a  frequent  source  of  adhesions. 
It  is  a  matter  of  common  observation  that  when  an  abdomen 
has  to  be  reopened,  some  months  or  perhaps  years  after 
an  abdominal  section  for  pelvic  disease,  the  omentum  will 
quite  commonly  be  found  adherent  to  some  portion  of  the 
pelvis  or  pelvic  organs,  whereas  the  bowel  is  only  rarely  so. 
This  marked  tendency  of  the  omentum  to  contract  adhesions 
appears  to  us  to  be  a  strong  argument  against  the  routine 
practice  of  -some  surgeons  who  tuck  the  free  edge  of  the 
omentum  down  into  the  pelvis  at  the  close  of  the  operation, 
for  where  the  omentum  is  inflamed  or  the  pelvis  the  seat 
of  peritonitis  such  a  proceeding  invites  the  formation  of 
adhesions. 

If  the  omentum  is  inflamed  or  adherent,  we  always 
remove  the  affected  portion,  and  at  such  a  level  that  the 
new  edge  is  well  above  the  brim  of  the  pelvis.  Great  care 
must  be  taken  in  suturing  the  peritoneal  layer  of  the  parietal 
wound,  for  if  gaps  be  left  in  it,  or  the  sutures  prematurely 
give  way,  the  intestine  rapidly  contracts  a  firm  adhesion 
to  the  under-surface  of  the  fascia  or  actually  forces  itself 
as  an  interstitial  hernia  between  the  layers  of  the  abdo- 
minal wall. 

ii.  Curative. — On  the  diagnosis  of  organic  obstruction 
several  courses  are  open  to  the  surgeon.  The  ideal  treat- 
ment, namely,  to  reopen  the  abdomen  and  relieve  the 
obstruction,  should  always  be  adopted  when  the  patient 
is  in  a  state  to  bear  the  operation.      In  this  connexion  it 


612  GYNECOLOGICAL  SURGERY 

is  to  be  remembered  that  the  operation  may  be  both 
difficult  and  lengthy  from  the  distension,  the  diffuse  adhe- 
sions which  may  be  present,  and  the  difficulty  of  identifying 
the  collapsed  portion  of  the  bowel  and  the  position  of  the 
obstruction.  The  extroversion  of  the  distended  intestines, 
which  results  from  the  large  incision  usually  necessary, 
besides  considerably  increasing  the  shock,  adds  yet  another 
difficulty  to  the  operation,  namely,  that  of  returning  the 
bowel  and  closing  the  wound  ;  in  fact,  this  is  sometimes 
impossible  until  the  gas  in  the  bowel  has  been  aspirated. 
In  advanced  acute  obstruction  the  mere  release  of  the 
imprisoned  gut  is  not  sufficient  unless  the  intestine  be  at 
the  same  time  emptied  of  the  noxious  faecal  matter  which 
it  contains.  We  think  that  where  the  obstruction,  though 
acute,  is  diagnosed  early,  or  where  it  is  subacute  or  chronic 
in  character  and  the  patient's  condition  good,  and  where 
its  location  can  be  gauged  with  fair  accuracy,  and  par- 
ticularly if  it  is  in  the  small  intestine,  an  attempt  should 
be  made  to  deal  with  the  actual  cause. 

But  if  the  patient  is  very  ill,  the  distension  very  great, 
the  seat  of  the  obstruction  unknown,  or  its  nature  sur- 
mised to  be  such  that  it  cannot  be  readily  rectified,  it  is 
best  to  perform  a  caecostomy  or  colotomy,  and  to  await 
a  more  favourable  time  for  dealing  with  the  origin  of 
the  trouble. 

With  respect  to  these  two  operations,  caecostomy  is  the 
one  of  choice  because  it  affords  a  greater  chance  of  success 
where  the  actual  site  of  the  obstruction  is  unknown  except 
that  it  is  somewhere  in  the  large  intestine.  Moreover,  the 
aperture  of  a  caecostomy  is  more  easily  closed,  either  by 
nature  or  by  art,  after  the  obstruction  has  been  overcome. 

Colotomy  should  be  performed  in  those  cases  where  a 
subsequent  attempt  to  overcome  the  obstruction  is  not 
in  immediate  anticipation,  or  where  this  may  have  been 
attempted  and  has  failed. 

In  obstruction  of  the  small  intestine  every  effort  must 
be  made  to  free  the  involved  portion  of  bowel,  because  the 


POSTOPERATIVE  COMPLICATIONS        613 

only  other  resource  is  the  formation  of  an  enteric  fistula, 
the  results  of  which,  if  a  portion  of  jejunum  is  opened,  are 
likely  to  be  disastrous.  If  the  existence  of  a  slight  partial 
obstruction  be  surmised  and  the  patient  be  not  materially 
ill,  expectant  treatment  may  be  adopted  in  the  hope  that 
the  bowel  may  right  itself.  Such  treatment  consists  in 
witholding  food  or  fluid  by  the  mouth  so  as  to  minimize 
peristalsis,  and  in  combining  rectal  feeding  with  the  regular 
use  every  four  hours  of  high  rectal  wash-outs.  It  is  most 
important  that,  in  his  endeavours  to  avoid  a  second 
operation,  the  surgeon  should  not  miss  the  favourable 
opportunity  for  relieving  the  obstruction. 

Paretic  Obstruction 

The  full  explanation  of  this  remarkable  condition  is 
not  apparent.  The  occurrence  is  fortunately  not  common 
nowadays,  owing  probably  to  improved  technique  and 
quicker  methods.  It  is  seen  almost  entirely  after  pro- 
longed operations  involving  much  manipulation  of  the 
intestines.  The  paralysis  is  usually  limited  to  one  par- 
ticular section  of  the  intestine,  and  in  the  cases  we  have 
operated  upon  this  has  usually  proved  to  be  the  lower  end 
of  the  small  intestine. 

Symptoms  and  signs. — The  symptoms  and  signs  are 
very  similar  to  those  of  organic  obstruction,  but  there  is 
an  absence  of  colicky  pain  and  intestinal  movement.  The 
condition  supervenes  during  the  first  week,  with  increasing 
distension  and  pulse-rapidity.  There  is  no  vomiting  at 
first,  and  flatus,  or  even  faecal  matter,  is  brought  away  by 
the  rectal  tube.  In  spite  of  this,  however,  the  distension 
increases,  the  shape  of  the  abdomen  indicating,  as  a  rule, 
that  it  is  the  small  intestine  that  is  becoming  distended. 
Vomiting  occurs,  first  in  small  quantities,  but  later  copi- 
ously, the  ejecta  being  a  dark-brown,  sour-smelling  fluid. 
At  the  close  it  may  be  actually  faecal.  In  some  cases  the 
symptoms  of  acute  dilatation  of  the  stomach  eventually 
supervene.     Judging   from   those   cases   we   have   operated 


614  GYNECOLOGICAL   SURGERY 

upon,  the  condition  is  as  follows  :  The  paralysed  portion 
of  the  intestine  is  collapsed  and  shrunken  ;  above  this  is  a 
section  greatly  distended  with  gas  but  containing  no  fluid 
contents,  while  the  yet  more  proximal  portion  of  the  gut 
(the  jejunum  in  most  cases)  is  distended  with  brown,  sour- 
smelling  or  faeculent  fluid  identical  with  that  vomited.  It 
is  most  important  to  realize  this  condition,  because  incision 
of  the  lower,  gas-distended  portion  of  the  intestine  is  quite 
useless,  the  paralysis  being  such  that  very  little  or  no 
relief  to  the  distension  is  afforded.  Whatever  the  cause, 
there  can  be  little  doubt  that  the  patient  actually  dies  from 
the  presence  in  the  upper  intestine  of  the  bacteria-laden 
fluid  described,  and  unless  this  can  be  evacuated  a  fatal 
termination  is  a  practical  certainty. 

Diagnosis — The  diagnosis  of  paretic  obstruction  from 
that  due  to  organic  occlusion  of  the  bowel  has  already  been 
discussed.  The  distinction  is  often  difficult,  but  the  absence 
of  colicky  pain  and  intestinal  movements  in  the  former 
condition  is  to  be  remembered. 

Treatment,  i.  Prophylactic.  —  Care  should  be  taken 
when  operating  not  to  handle  the  intestines  more  than  is 
necessary,  and  particularly  to  avoid  prolonged  traction  on 
the  mesenteries,  for  the  condition  is  probably  due  to  injury 
to  the  splanchnic  nerves  contained  therein.  Particularly 
should  excessive  packing  of  swabs  or  gauze  for  the  purpose 
of  restraining  the  intestines  be  avoided.  The  forcing  of 
the  intestines  into  the  upper  abdominal  cavity  stretches 
the  mesenteries  and  is  liable  to  injure  them. 

ii.  Curative. — On  the  appearance  of  the  symptoms  the 
methods  described  under  the  heading  of  paretic  distension 
(p.  587)  should  be  vigorously  applied.  If  this  is  done  early 
the  condition  is  usually  overcome.  Where  they  fail  to 
reduce  the  distension,  and  particularly  where  brown,  sour- 
smelling  fluid  is  beginning  to  be  vomited,  operative  inter- 
ference holds  out  the  only  chance.  The  abdominal  wound 
should  be  reopened  and  the  state  of  affairs  explored,  par- 
ticularly in  regard  to  the  possibility  of  an  organic  cause 


POSTOPERATIVE  COMPLICATIONS        615 

for  the  obstruction.  In  its  absence  the  bowel  should  be 
opened  after  being  stitched  into  the  wound.  The  exact 
site  of  this  will  depend  upon  the  case,  but  in  general,  and 
particularly  where  brown  vomit  is  being  ejected,  it  is  most 
necessary  to  tap  that  part  of  the  intestine  which  forms  the 
reservoir  containing  it.  It  will  therefore  be  best  to  open 
the  upper  part  of  the  ileum,  or  even  the  jejunum,  and  insert 
a  Paul's  tube.  If  the  operation  is  successful,  large  quantities 
of  the  brown  intestinal  contents  will  be  evacuated  for  a 
day  or  two,  and  the  vomiting  will  immediately  cease.  If 
the  patient  survive,  normal  small-intestine  contents  will 
then  begin  to  escape,  and  emaciation  rapidly  follows.  The 
closing  of  the  artificial  opening  should  be  postponed  as 
long  as  is  safe,  but  eventually  it  must  be  undertaken. 
The  best  method,  we  think,  is  to  resect  the  attached  portion 
of  gut  and  perform  an  end-to-end  anastomosis.  No  fear 
need  be  entertained  that  the  intestine  below  will  not  have 
recovered  its  power  and  that  the  condition  will  return. 
The  measures  indicated  are  of  course  severe,  but  we  have 
successfully  applied  them  when  all  the  ordinary  means  of 
overcoming  paretic  distension  had  failed. 


CHAPTER    XXXVI 
POSTOPERATIVE    COMPLICATIONS   (Continued) 

HEART-FAILURE 

As  mentioned  elsewhere,  the  commonest  cause  of  death 
after  an  abdominal  operation  in  these  days  is  a  primary 
cardiac  failure,  the  autopsy  disclosing  no  cause  of  death 
other  than  the  condition  of  the  heart.  Many  of  the  most 
serious  operations  have  to  be  performed  on  elderly  and 
enfeebled  patients,  and  it  is  in  such  that  the  special  risk 
of  cardiac  failure,  quite  apart  from  some  other  causative 
condition  such  as  sepsis,  is  to  be  encountered.  Primary  car- 
diac failure  usually  occurs  in  persons  with  fatty  hearts  as  a 
result  of  the  operation  imposing  on  the  cardiac  muscle  a 
relatively  too  severe  strain. 

It  is  just  this  class  of  patient  in  whom  the  stamina  of 
the  cardio-vascular  system  is  so  difficult  to  gauge.  The 
preoperative  duties  of  the  surgeon  in  this  connexion  have 
already  been  referred  to. 

Symptoms. — -The  chief  symptom  is  a  progressively  rapid 
heart-action,  associated  with  an  increased  respiration-rate, 
a  feeble,  flapping  first  sound,  and  the  gradual  progress 
outwards  of  the  apex-beat  beyond  the  nipple -line,  while 
the  condition  of  the  abdomen  and  the  temperature  negative 
any  disaster  at  the  operation-site. 

Treatment. — The  sheet-anchors  of  the  surgeon  in  this 
condition  Mall  be  strychnine  and  brandy,  3  minims  of  the 
former  given  hypodermically  every  four  hours,  and  4  to  8 
ounces  daily  of  the  latter  by  the  mouth  or  rectum.  Cham- 
pagne may  also  be  usefully  employed. 

Digitalis  should  never  be  given,  since  it  not  only  always 
fails  to  lower  the  pulse-rate,  but  makes  it  irregular.     As 

616 


POSTOPERATIVE  COMPLICATIONS        617 

much  nourishment  should  be  given  to  the  patient  as  she 
is  able  to  take. 

HYPERPYREXIA 

Temperatures  above  1040  F.  after  abdominal  section  are 
of  the  very  gravest  import,  especially  if  the  rise  be  con- 
tinuous. It  usually  indicates  peritonitis  or  some  profound 
toxaemia,  and  the  patient  is  almost  certain  to  die. 

Treatment.  — ■  The  primary  cause  must  be  treated,  if 
possible,  and  for  the  fever  itself  tepid  sponging,  or  an  ice- 
cradle,  may  be  tried. 

SEPTICAEMIA    AND    PYEMIA 

These  very  serious  and  usually  fatal  complications  are 
most  likely  to  happen  in  the  first  week,  and  may  occur 
after  any  operation. 

Symptoms  and  signs.  —  The  patient  will  present  the 
symptoms  of  fever ;  the  temperature  will  be  high  and  re- 
mittent, the  pulse  rapid,  and  the  respirations  quick.  The 
skin  may  be  jaundiced  or  covered  with  a  scarlatinal  eruption, 
and  the  bowels,  which  at  first  are  constipated,  will  become 
loose.  The  spleen  may  become  enlarged,  and  secondary 
inflammatory  foci,  such  as  septic  pneumonia,  pleurisy, 
pericarditis,  or  arthritis,  may  appear.  The  face  is  haggard 
but  flushed,  and  the  mind  till  the  very  end  is  exceptionally 
clear.  There  is  usually  a  complete  want  of  perception  of 
the  imminence  of  death.  In  pyaemia,  with  the  above  signs 
and  symptoms,  local  abscesses  form  in  the  pleura,  lungs, 
joints,  or  liver. 

Treatment. — The  patient  must  be  supported  by  every 
means  as  long  as  possible,  and  every  attempt  made  to 
increase  the  natural  resistance.  To  this  end,  if  the  causative 
organism  is  known,  a  vaccine  may  be  prepared  and  ad- 
ministered. It  has  most  chance  of  success  in  the  more 
chronic  cases,  and,  pending  a  definite  bacteriological  diag- 
nosis, antistreptococcic  serum  should  be  given  in  large  doses. 
All  secondary  abscesses  should  be  opened  where  possible. 


6i8  GYNECOLOGICAL  SURGERY 

If  the  wound  is  suppurating  it  must  be  freely  opened  up, 
irrigated  and  drained. 

TETANUS 

In  this  country  postoperative  tetanus  is  almost  invari- 
ably due  to  the  use  of  imperfectly  sterilized  catgut.  The 
matter  has  already  been  discussed  when  dealing  with  that 
suture  material. 

Treatment.  —  In  such  a  disastrous  event  the  patient, 
if  not  in  a  single  ward,  should  be  removed  to  one,  which 
must  be  darkened,  and  no  one  except  the  nurse  and  doctor 
allowed  to  enter  it.  Every  endeavour  must  be  made  to 
"  keep  the  patient  going,"  since  if  the  disease  lasts  over 
four  days  the  prognosis  is  much  more  favourable. 

Up  to  the  present  no  medicine  has  been  found  to  cure 
the  disease.  All  the  surgeon  can  do  is  to  see  that  as  much 
nourishment  as  possible  is  taken,  to  prescribe  drugs  which 
will  relieve  the  spasms,  and  to  inject  antitetanic  serum 
to  neutralize  the  toxin. 

With  regard  to  nourishment :  when  the  spasms  pre- 
vent the  patient  taking  food  in  the  ordinary  way,  she  should 
be  fed  with  a  stomach-tube  if  possible,  or  with  a  catheter 
passed  through  the  nose.  Rectal  feeding  is  unsatisfactory. 
For  the  spasms  the  patient  may  be  kept  under  the  influence 
of  morphia ;  chloral  or  chloroform  may  be  administered, 
the  latter  not  being  without  danger  owing  to  the  risk  of 
syncope  supervening  on  a  respiratory  spasm.  Antitetanic 
serum  has  proved  disappointing  in  the  acute  cases,  though 
in  the  subacute  it  has  met  with  more  success,  and  at  any 
rate  it  should  always  be  used.  An  injection  of  30  c.c.  should 
be  given  under  the  skin  of  the  abdomen,  followed  by  one  of 
15  c.c.  twice  daily.  Injections  of  2*5  c.c.  of  the  dried 
serum  in  5  c.c.  of  distilled  water  into  the  frontal  lobes  of 
the  brain  every  few  days  have  also  proved  successful. 

In  the  absence  of  antitetanic  serum,  Baccelli  has  had 
success  with  injections  of  15  minims  of  a  2  per  cent,  solution 
of  carbolic  acid  three  times  daily  till  the  symptoms  disappear. 


POSTOPERATIVE   COMPLICATIONS        619 

PYLEPHLEBITIS 

Pylephlebitis  is  a  rare  cause  of  death  after  opera- 
tions on  the  pelvic  organs.  When  it  occurs,  it  is  due  to 
embolic  extension  from  septic  thrombosis  in  some  of  the 
veins  of  the  portal  area.  Thus,  in  some  cases  of  acute  sal- 
pingitis, or  of  suppurating  or  gangrenous  tumours,  portions 
of  the  bowel,  mesentery,  or  omentum  may  become  involved 
in  the  process,  and  the  infection,  extending  to  the  veins 
of  those  parts,  may  be  the  starting-point  of  the  disaster. 

Symptoms. — At  first  nothing  beyond  an  undue  rapidity 
of  the  pulse  may  be  noted,  not  explainable  by  the  condition 
of  the  operation-area.  Within  forty-eight  hours  jaundice 
appears.  Vomiting  becomes  persistent,  the  ejecta  con- 
taining blood  in  variable  quantity,  and  the  patient  rapidly 
sinks,  coma  supervening  before  death. 

The  temperature  is  not  necessarily  raised. 

Treatment. — Continuous  saline  infusion  into  the  cellular 
tissue  may  be  tried  (p.  579),  and  antitoxic  serum  may  be 
administered,    but    we    are  not  aware  of  any  reported  re 
covery  after  the  symptoms  noted  have  been  established. 

PAROTITIS 

The  cause  of  this  complication  is  not  surely  known, 
though  some  cases  may  be  due  to  oral  sepsis.  It  probably 
forms  part  of  a  general  sepsis,  especially  when  bilateral.  It 
is  a  remarkable  fact  that,  whereas  some  years  ago  instances 
of  this  complication  were  not  uncommon  in  our  experience, 
for  a  long  time  we  have  rarely  seen  a  case,  probably  owing 
to  the  improvement  in  the  technique  of  aseptic  surgery- 
It  is  more  common  where,  for  some  reason,  mouth-feeding 
has  been  prohibited. 

Symptoms.  —  The  condition  usually  supervenes  within 
the  first  three  weeks,  and,  as  a  rule,  only  one  gland  is 
affected.  The  gland  is  swollen  and  tender,  the  temperature 
and  the  pulse-rate  are  raised ;  the  patient  is  unable  to  take 
her    food   properly,  and   feels    very   ill.      Occasionally   the 


620  GYNECOLOGICAL  SURGERY 

gland  suppurates,  and  especially  is  this  likely  to  occur  in 
those  patients  who  are  cachectic  and  enfeebled. 

If  suppuration  takes  place  there  is  much  constitutional 
depression  with  great  pain.  If  the  abscess  is  not  opened 
it  may  burst  into  the  auditory  meatus,  or  on  the  cheek 
or  neck  ;  it  may  track  down  in  the  tissues  of  the  neck 
or  ulcerate  into  the  external  carotid  artery.  The  gland 
sloughs,  and  more  or  less  facial  paralysis  may  exist,  and 
even  remain  permanently  after  the  inflammatory  process 
has  subsided. 

Treatment.  — ■  In  the  milder  cases,  painting  with  bella- 
donna and  glycerine  and  the  application  of  a  wool  pad  are 
all  that  is  required.  When  the  skin  becomes  dusky  these 
measures  should  be  changed  for  fomentations,  and  cautious 
incisions  in  lines  corresponding  to  the  important  vessels 
and  nerves  of  this  region.  Plenty  of  stimulants  and  a 
liberal  diet  are  necessary. 

If  ulceration  takes  place  into  the  external  carotid  artery 
it  will  probably  be  necessary  to  ligature  the  common  carotid, 
as  the  oedema  and  swelling  extend  too  far  down  the  neck 
to  render  it  possible  to  reach  the  external  carotid  through 
healthy  tissues. 

THROMBOSIS    OF   FEMORAL    VEIN 

This  most  interesting  complication  appears  late.  On 
referring  to  a  considerable  number  of  the  cases,  we  find 
that  in  the  great  majority  of  them  the  symptoms  de- 
veloped between  the  eleventh  and  thirteenth  day  after  the 
operation. 

Symptoms  and  signs.  —  The  complication  is  usually 
ushered  in  by  fever,  a  sallow  face,  and  marked  malaise,  the 
condition  of  the  patient  before  this  having  perhaps  been 
quite  satisfactory.  The  leg  is  very  tender  when  first  swollen, 
and  the  pain  usually  precedes  the  swelling,  and  is  variously 
localized,  sometimes  in  the  course  of  the  inflamed  vein, 
but  not  uncommonly  on  the  outer  side  of  the  leg.  The 
swelling  may  be  limited  to  an  enlargement  of  the  thigh, 


POSTOPERATIVE  COMPLICATIONS        621 

which  does  not  pit  on  pressure,  or  there  may  be  oedema 
of  the  whole  or  part  of  the  leg.  After  being  acutely  tender 
and  painful  for  a  few  days,  the  leg  gradually  improves. 
A  relapse  may  occur,  and  a  tendency  to  swelling  of  the 
leg  is  left  for  many  months.  The  most  striking  thing  about 
this  complication  is  the  varied  nature  of  the  operations 
preceding  it.  Thus,  we  have  seen  it  occur  after  abdominal 
hysterectomy,  after  vaginal  hysterectomy,  and  after  simple 
incision  of  the  abdominal  wall  ;  and  we  have  known  a  left 
femoral  thrombosis  follow  on  the  removal  of  a  right  ovarian 
cyst  through  an  abdominal  incision.  Its  occurrence  after 
vaginal  hysterectomy  shows  that  it  is  not  necessarily  due 
to  a  spreading  thrombosis  of  the  superficial  epigastric  veins 
secondary  to  some  infection  through  the  cut  edges  of  the 
abdominal  wound,  for,  though  this  may  be  one  channel 
of  infection,  it  is  evident  from  its  occurrence  without  an 
abdominal  wound  that  there  must  be  others.  There  is 
no  direct  communication  between  the  veins  in  the  broad 
ligaments  and  the  external  iliac  vein,  and,  even  if  there 
were,  it  would  not  explain  left  thrombosis  after  right  ovari- 
otomy. That  it  has  followed  on  simple  abdominal  incision 
without  interference  with  the  pelvic  organs  is  remarkable. 
Again,  it  is  nearly  always  the  left  leg  which  is  affected, 
though  the  right,  or  both,  may  suffer.  In  some  cases  the 
popliteal  or  deep  tibial  veins  would  appear  to  be  primarily 
thrombosed.  In  these  cases  the  infecting  agent  must  have 
travelled  against  both  venous-blood  and  lymph-stream. 
The  whole  subject  is  involved  in  mystery,  and  it  well 
merits  careful  investigation.  It  appears  to  us  that  the 
balance  of  evidence  is  in  favour  of  a  general  systemic 
infection  with  a  local  spot  of  "  least  resistance."  It  is 
more  especially  liable  to  occur  in  anaemic  women. 

Treatment. — The  leg  must  be  kept  absolutely  at  rest  ; 
it  should  be  elevated  by  placing  the  foot  on  a  pillow,  and 
kept  fixed  by  sand-bags,  a  cradle  being  used  to  keep  off 
the  pressure  of  the  bedclothes.  Locally,  glycerine  and 
belladonna  may  be  applied  with  or  without  superimposed 


622  GYNECOLOGICAL   SURGERY 

hot  fomentations,  after  which  the  leg  should  be  firmly  but 
gently  bandaged.  A  high  temperature  must  be  treated 
with  quinine  or  sponging,  if  necessary,  and  the  pain  may 
be  so  severe  that  morphia  is  required  for  its  alleviation. 
There  is  always  a  danger  of  the  clot  becoming  displaced, 
with  resulting  pulmonary  embolism,  and  the  patient  must 
therefore  be  warned  to  keep  her  leg  still.  The  leg 
must  not  be  lowered  until  all  pain  and  fever  and  most 
of  the  swelling  have  disappeared ;  it  should  then  be 
firmly  bandaged. 

EMBOLISM  OF  THE  FEMORAL  ARTERY 

We  have  seen  one  case  following  hysterectomy.  On  the 
eighth  day  the  left  leg  became  suddenly  white  and  cold ;  a 
week  after  the  right  leg  was  similarly  affected.  A  line  of 
demarcation  formed  in  the  middle  of  the  thighs  three  days 
later,  and  gangrene  began  two  days  after  that.  The  com- 
plication was  presumably  due  to  septic  endocarditis. 

THROMBOSIS    OF    THE    INFERIOR    VENA    CAVA 

We  have  seen  two  examples  following  hysterectomy. 
The  first  patient  died  suddenly  after  three  days  fever. 
The  cava  and  ovarian  veins  were  thrombosed.  In  the  second 
the  symptoms  were  slower  with  oedema  of  both  legs,  a  peculiar 
bronzing  of  the  skin  and,  later,  vomiting.  The  cava  con- 
tained organised  clot,  and  eighteen  inches  of  ileum  were  gan- 
grenous from  thrombosis  of  mesenteric  veins. 

ACUTE   DILATATION    OF   THE    STOMACH 

This  is  a  very  rare  complication.  Of  44  cases  collected 
by  Campbell  Thomson  in  his  book  on  the  subject,  no 
less  than  12  were  associated  with  surgical  operations, 
but  of  these  12  only  4  followed  an  abdominal  section. 
In  severe  cases,  acute  dilatation  of  the  stomach  is  one  of 
the  most  dangerous  complications. 

The  symptoms  are  usually  sudden.      The  patient  com- 


POSTOPERATIVE   COMPLICATIONS        623 

plains  of  discomfort  and  fullness  in  the  abdomen,  the  tem- 
perature falls,  the  pulse-rate  rises,  the  urine  becomes  scanty 
or  suppressed,  and  death  occurs  in  a  few  hours.  An 
examination  of  the  abdomen  shows  that  it  is  distended, 
and  a  sense  of  fluctuation  and  a  succussion  splash  may 
often  be  obtained.  The  onset  is  soon  followed  by  the 
vomiting  of  large  quantities  of  a  fluid  of  a  greenish  colour. 
Usually  the  condition  is  primarily  a  paralytic  one,  due 
probably,  as  Campbell  Thomson  says,  to  the  circulation  of 
poisons  derived  from  the  alimentary  canal  or  some  acute 
infection.  It  may,  as  we  have  pointed  out,  be  the  terminal 
result  of  paretic  obstruction. 

With  regard  to  treatment,  rectal  feeding  should  be 
ordered,  and  the  stomach-tube  should  be  passed  at  regular 
intervals  and  the  contents  of  the  stomach  drawn  off. 
Strychnine  should  be  given  hypodermically. 

We  have  had  one  example  of  this  complication.  It 
followed  the  removal  of  a  double  pyo-salpinx,  in  the  wall 
of  which  Dr.  Taylor,  the  obstetrical  registrar,  found  the 
gonococcus.  The  operation  was  a  very  difficult  one,  and 
pus  escaped  during  the  necessary  manoeuvres.  The  patient 
seemed  to  progress  quite  satisfactorily  for  two  days,  when 
she  was  suddenly  seized  with  acute  abdominal  pain,  due 
to  what  she  described  as  "a  fullness  of  the  stomach."  An 
examination  showed  the  abdomen  to  be  very  distended  but 
not  tender,  and  the  stomach  very  dilated.  The  temperature 
was  just  above  normal,  the  pulse  considerably  faster  than  the 
temperature  warranted.  In  a  few  hours  the  patient  had 
vomited  nine  pints  of  a  greenish  fluid.  The  stomach-tube 
was  used  and  three  pints  of  this  fluid  was  drawn  off.  For  a 
few  days  the  stomach-tube  was  used  every  four  hours,  the 
amount  withdrawn  being  gradually  less,  and  the  distension 
subsiding,  till  at  length  the  stomach  became  normal.  Strych- 
nine was  also  given.  Unfortunately,  as  the  patient  was 
convalescing,  bronchitis  supervened  and  terminated  fatally. 
At  the  post-mortem  examination  the  stomach  was  found 
the  natural  size,  and  there  was  no  peritonitis. 


624  GYNECOLOGICAL  SURGERY 

HICCOUGH 

Hiccough  may  be  due  to  some  inflammatory  condition 
of  the  abdomen,  such  as  peritonitis,  appendicitis,  or  intes- 
tinal obstruction.  It  may  be  due  to  gastritis,  flatulent 
dyspepsia,  or  an  overloaded  stomach ;  or  it  may  be  an 
indication  of  some  general  disease,  such  as  diabetes  or 
chronic  nephritis.  It  occasionally  complicates  cardiac  fail- 
ure, pneumonia,  and  pleurisy  ;  whilst  sometimes  it  is  present 
with  cerebral  tumour.      Often  no  cause  can  be  discovered. 

In  the  old  days  the  occurrence  of  hiccough  was  con- 
sidered to  be  of  the  gravest  import.  Probably  it  gained 
this  sinister  reputation  from  the  fact  that  it  not  infrequently 
accompanies  general  peritonitis.  We  have,  however,  fre- 
quently seen  it  more  or  less  marked,  quite  apart  from 
any  grave  abdominal  complication,  and  it  is  generally  in 
these  cases  due  to  some  gastric  disturbance.  In  one  case 
we  remember  hiccough  continuing  for  three  days  and 
nights  before  it  was  relieved. 

Treatment — ■  Many  remedies  may  have  to  be  tried 
before  relief  is  obtained.  Among  these  we  may  mention 
warm  applications  to  the  abdomen,  freezing  the  skin  in 
the  epigastric  region,  or  along  the  neck  in  the  course  of 
the  phrenic  nerve,  with  the  ether  spray.  Holding  the 
breath,  strong  traction  on  the  tongue,  taking  a  little  snuff 
to  induce  sneezing,  are  remedies  which  at  times  are  suc- 
cessful. Drinking  water  from  a  glass  with  the  mouth 
applied  to  the  distal  part  of  its  circumference,  thus  necessi- 
tating flexion  of  the  trunk,  will  at  times  succeed  where 
other  measures  have  failed.  Of  drugs,  aromatic  spirits  of 
ammonia,  a  little  neat  brandy,  morphia,  nitro-glycerine, 
ergot,  or  turpentine  may  be  prescribed ;  and  Foot  cured  a 
boy,  who  hiccoughed  on  an  average  840  times  an  hour  for 
twenty-six  weeks  (except  when  asleep),  with  a  pill  of  iodo- 
form, extract  of  Indian  hemp,  and  extract  of  hemlock. 

If  hiccough  is  due  to  gastric  disturbance,  the  stomach 
may  be  washed  out  or  an  emetic  given  if  other  remedies  fail. 


POSTOPERATIVE  COMPLICATIONS        625 

HEMORRHAGE   FROM   THE   STOMACH 

Slight  degrees  of  haematemesis  not  infrequently  occur 
after  abdominal  section  for  pelvic  disease.  The  vomit 
resembles  coffee-grounds  in  colour  and  appearance,  and  the 
blood  is  probably  due  to  capillary  oozing  from  the  con- 
gested stomach-wall.  No  particular  treatment  is  required 
for  this  (see  p.  584).  Occasionally  severe  haemorrhage  may 
occur,  which  in  some  cases  is  certainly  due  to  ulceration 
of  the  stomach,  for  gastric  ulcers  have  been  found 
post-mortem.  In  a  good  number  of  cases  on  record  a  perfora- 
tion of  the  ulcer  has  occurred.  Both  these  complications  in 
a  patient  suffering  from  gastric  ulcer  are  probably  brought 
about  either  by  (a)  congestion  of  the  stomach-wall  produced 
by  the  anaesthetic  ;  (b)  the  effort  of  vomiting  ;  or  (c)  the 
flatulent  gastric  distension  that  so  often  occurs  after  abdo- 
minal section. 

Treatment.  —  The  treatment  is  that  of  haemorrhage 
from  or  perforation  of  a  gastric  ulcer  in  circumstances  un- 
connected with  abdominal  section. 

HEMORRHAGE   FROM   THE    BOWEL 

The  passage  of  blood  from  the  bowel  after  abdominal 
section  is  a  rare  occurrence.  When  it  occurs  it  is  due 
either  to  some  local  injury  of  the  bowel,  gangrene  of  the 
bowel,  ulcerative  colitis,  or  an  ulcer  of  the  duodenum  or 
stomach. 

The  subject  of  operative  injury  to  the  bowel  has  already 
been  dealt  with  (p.  545).  Of  ulcerative  haemorrhagic  colitis 
we  have  met  with  one  example.  The  symptoms  came  on 
some  days  after  the  operation,  and  were  those  of  a  foul- 
smelling  diarrhoea,  mixed  with  increasing  quantities  of 
blood  and  sloughs,  which  no  treatment  alleviated.  At  the 
post-mortem  examination  the  whole  of  the  large  intestine 
was  found  to  be  the  seat  of  deep  multiple  ulceration. 

Should  we  encounter  another  case  of  this  description 
we  should  perform  caecostomy.  The  treatment  of  gastric 
ulcer  has  been  discussed.  Should  a  duodenal  ulcer  be 
2  o 


626  GYNAECOLOGICAL    SURGERY 

diagnosed,  a  gastro-enterostomy  should  be  performed  if 
the  patient  is  in  a  fit  state  to  bear  it.  The  subject  of  gan- 
grene of  the  bowel  demands  a  separate  section. 

GANGRENE   OF   THE   BOWEL 

It  sometimes  happens  that  in  the  course  of  an  opera- 
tion a  portion  of  the  mesentery  may  be  so  damaged  that 
the  blood-supply  to  a  certain  length  of  the  bowel  is 
interfered  with.  This  is  much  more  likely  to  happen 
when  the  mesentery  of  the  small  intestine  is  injured, 
because  the  vascular  anastomosis  there  is  much  less  free 
than  in  the  case  of  the  mesocolon.  It  is  also  liable  to  occur 
at  the  point  where  an  end-to-end  anastomosis  has  been 
performed.  The  symptoms  are  those  of  progressive  disten- 
sion and  peritonitis,  and  in  some  cases  its  presence  is  made 
clear  by  the  passage  of  large  quantities  of  blood  per  anum. 

Treatment.  — ■  The  surgeon  should  be  careful,  when 
resecting  intestine,  not  to  interfere  with  the  mesenteric 
blood-supply  of  the  cut  ends.  Also,  when  intramesenteric 
tumours  have  been  removed,  the  corresponding  portion  of 
the  bowel  must  be  closely  inspected  for  that  purplish  hue 
which  indicates  that  its  blood-supply  is  interfered  with, 
in  which  case  it  must  be  resected. 

If,  subsequently  to  the  operation,  the  surgeon  diagnoses 
gangrene  of  the  bowel,  and  on  opening  the  abdomen  finds 
his  diagnosis  correct,  he  must  either  resect  the  gangrenous 
portion  and  perform  an  anastomosis,  or  bring  the  whole 
coil  outside,  cut  off  the  gangrenous  portion,  and  stitch  the 
open  ends  into  the  wound. 

CONSTIPATION 

Almost  all  patients  after  abdominal  section  have  more 
or  less  constipational  trouble.  This  is  probably  due  to 
the  altered  relations  of  the  parts,  the  altered  pressure  con- 
ditions obtained  in  the  abdomen,  the  reclining  posture, 
and  the  deviation  from  the  natural  diet.  During  con- 
valescence  it  thus  happens  that  patients  who  never  before 


POSTOPERATIVE   COMPLICATIONS        627 

had    any  trouble  with  their  bowels  are  now  the  subjects 
of  constipation. 

Treatment. — Constipation  in  the  first  week  is  best  re- 
lieved by  an  enema  of  soap-and-water  ;  after  this  a  daily 
action  may  be  secured  by  such  purgatives  as  the  patient 
is  usually  accustomed  to  take.  In  obstinate  cases  the 
following  prescription  will  be  found  very  serviceable  : — 

J£   Ext.  cascar.  sagrad.  liq.   5*- 
Mag.  sulph.  5L 
Tinct.  hyoscyami  5SS- 
Aq.  menth.  pip.  ad   51. 

Dose,  two  teaspoonfuls  to  two  tablespoonfuls. 

When  there  is  the  slightest  suspicion  that  there  exists  some 
interference  with  the  free  action  of  the  bowel  by  kinking,  pres- 
sure, or  any  other  cause  of  intestinal  obstruction,  no  purga- 
tives by  the  mouth  should  be  administered.  In  such  cases 
we  know  of  nothing  better  than  large  injections  of  from 
16  to  20  ounces  of  warm  olive  oil  slowly  introduced  high 
up  into  the  bowel  by  a  long  rectal  tube  and  retained 
as  long  as  possible. 

DIARRHOEA 

Diarrhoea  after  abdominal  section  is  not  a  common 
complication,  and  when  it  occurs  is  of  bad  omen. 

Causes. — Diarrhoea  may  be  due  to  the  following  causes  : — 

i.  Intestinal  obstruction.  —  When  the  large  intestine 
is  partially  obstructed,  especially  in  its  pelvic  course, 
diarrhoea  frequently  occurs,  due  to  the  stercoral  colitis 
set  up  above  the  seat  of  stricture.  This  sign  is  a  very 
important  one,  and  its  significance  is  apt  to  be  overlooked. 
The  motions  passed,  always  liquid,  are  small  in  amount, 
though  the  actions  are  frequent.  In  deciding  whether  the 
diarrhoea  is  due  to  obstruction,  the  surgeon  must  take  into 
account  the  relation  borne  by  the  amount  of  material 
passed  per  anum  to  that  taken  per  os,  together  with  the 
presence  or  absence  of  those  other  signs  of  intestinal  obstruc- 
tion which  will  be  found  detailed  at  p.  608. 


628  GYNECOLOGICAL   SURGERY 

ii.  Pelvic  inflammation. —When  the  pelvic  colon  is 
surrounded  by  an  inflammatory  mass,  such  as  occurs  in 
pelvic  peritonitis  or  cellulitis  following  an  operation, 
diarrhoea  frequently  occurs,  and  the  supervention  of  this 
complication,  accompanied  by  temperature  and  pelvic  pain, 
should  lead  one  to  make  a  vaginal  examination. 

iii.  Acute  ulcerative  colitis. — See   p.    625. 

iv.  Sepsis.- — -Persons  dying  from  generalized  sepsis  usually 
exhibit  more  or  less  diarrhoea ;  the  motions  are  almost 
unconsciously  passed,  although  the  intellect  appears  active. 
It  is  a  sure  sign  of  impending  death. 

INJURIES  RESULTING  FROM  RECTAL  INJECTIONS 
The    following   injuries   may   result    from   rectal   injec- 
tions : — 

1.  The  injection  may  be  too  hot,  and  the  bowel  con- 
sequently scalded. 

2.  The  nozzle  of  the  Higginson's  syringe,  if  this  instru- 
ment is  used,  has  been  pushed  through  the  bowel-wall  and 
the  enema  delivered  into  the  peritoneal  cavity. 

3.  The  bowel- wall  may  be  so  attenuated  after  separation 
from  tumours,  inflammatory  masses,  etc.,  that,  though  not 
perforated  at  the  time,  it  may  subsequently  give  way 
under  the  pressure   of  a  large  rectal  injection. 

4.  The  bowel  may  have  been  accidentally  opened  during 
an  operation,  and  the  sutures  closing  such  openings  may 
burst  from  the  pressure  of  the  rectal  injection. 

Treatment. — The  treatment  of  these  disasters  is  prin- 
cipally prophylactic.  If  the  nurse  take  sufficient  care, 
and  nothing  more  solid  than  the  soft  rectal  tube  be  used, 
the  injuries  noted  under  1  and  2  should  not  occur.  In 
cases  where  the  bowel  has  been  damaged,  rectal  injections 
should  be  avoided,  except  under  great  necessity.  If  the 
bowel  has  been  ruptured,  the  proper  course  to  pursue  is 
immediately  to  open  the  abdominal  wound,  suture  the 
rent  if  possible,  wash  out  the  pelvic  cavity,  and  drain  with 
the  patient  in  the  sitting  posture. 


CHAPTER    XXXVII 
POSTOPERATIVE  COMPLICATIONS   (Continued) 

COMPLICATIONS   IN   THE   ABDOMINAL  WOUND 

The  complications  that  may  occur  in  the  abdominal 
wound  are  hematoma,  abscess,  sloughing,  sinus,  faecal 
fistula,  bursting,  scar-hernia,  emphysema,  etc. 

HEMATOMA 

This  condition  is  very  likely  to  arise  if  trouble  is  not 
taken  to  stop  any  sharp  oozing  at  the  skin-edge  or  from 
the  subcutaneous  tissues.  Also,  when  suturing  the  fascial 
or  skin-layer,  a  vessel  may  be  pricked  with  the  needle, 
and,  escaping  notice  at  the  time,  give  rise  to  a  haematoma. 
Haematoma  of  the  abdominal  wound  is  generally  discovered 
when  the  skin-stitches  are  removed  at  the  end  of  a  week, 
but  since  an  irregular  temperature,  as  a  rule,  accompanies 
this  condition,  it  should  be  detected  sooner. 

The  best  treatment  is  to  open  up  the  cavity  and  scrape 
out  the  clot,  and,  if  the  cavity  be  small,  to  powder  it  thickly 
with  aristol  and  let  it  granulate  up,  which  it  does  rapidly 
when  kept  dry.  If  the  cavity  be  large,  it  had  better  be 
closed  anew  with  silkworm-gut  sutures. 

Abscess 

Abscess  of  the  abdominal  wound  may  be  due  to  the 
insertion  of  an  infected  suture,  or  to  infection  of  the  wound 
from  the  organisms  in  the  patient's  skin  or  abdominal 
cavity,  or  to  want  of  surgical  cleanliness  of  the  surgeon's  or 
his  assistants'  hands,  or  to  a  haematoma  which  has  sub- 
sequently become  invaded  by  organisms.  The  abscess 
may  declare  itself  any  time  from  a  few  days  following  the 

629 


630  GYNECOLOGICAL   SURGERY 

operation  to  (in  the  case  of  some  stitch-abscesses)  months 
afterwards. 

Abscess  most  commonly  affects  one  of  the  interrupted 
sutures  of  the  fascial  layer,  and  we  believe  that  the  usual 
route  of  infection  is  along  the  track  formed  by  the  sutures 
uniting  the  skin.  We  think  that  this  complication  will  be 
seen  less  often  if  Michel's  clips  are  used.  Fever  with  nothing 
to  account  for  it  should  always  awaken  suspicion  of  sup- 
puration round  a  buried  suture.  The  pulse  may  increase  a 
little  in  rapidity,  pain  in  the  neighbourhood  of  the  wound 
will  be  complained  of,  and  if  this  be  examined  an  indurated 
or  fluctuating  swelling  will  be  felt. 

When  the  suppuration  affects  the  continuous  suture 
used  for  the  peritoneum  it  causes  much  trouble,  for  there 
is  a  diffuse  deep-seated  induration  along  the  whole  length 
of  the  wound  and  multiple  sinuses  are  formed. 

Treatment.  —  The  pus  must  be  let  out  as  soon  as  it 
is  detected,  and  if  it  is  thought  to  be  due  to  a  stitch,  this 
should  also  be  removed,  if  possible.  In  most  cases  the 
suppuration  takes  place  just  beneath  the  skin,  and  slightly 
opening  the  wound  will  allow  the  pus  to  escape,  after 
which  the  cavity  should  be  packed  with  gauze  and  the 
wound  allowed  to  granulate  up. 

The  most  troublesome  cases  are  those  of  deep-seated 
suppuration  along  the  suture  uniting  the  peritoneum, 
especially  in  fat  patients.  In  such  circumstances  the  pus 
does  not  readily  come  to  the  surface,  the  area  of  induration 
is  diffuse,  and  in  many  cases  a  degree  of  local  peritonitis 
is  present  as  well,  with  symptoms  of  a  certain  amount  of 
interference  with  the  intestine.  Such  a  condition  may  at 
first  be  temporized  with,  hot  fomentations  being  applied 
meanwhile  in  the  hope  that  the  inflammatory  effusion  may 
subside. 

In  the  event  of  incision  being  necessary,  the  greatest 
care  should  be  taken,  for  omentum  always,  and  intestine 
commonly,  will  be  found  densely  adherent  to  the  parietal 
wound. 


POSTOPERATIVE   COMPLICATIONS        631 

Where  extensive  stitch-suppuration  has  occurred  there 
is  a  risk  of  subsequent  ventral  hernia,  and  the  patient 
should  be  made  to  wear  an  abdominal  belt  for  a  year  or 
two. 

Sloughing  of  the  Abdominal  Wound 

In  operations  of  a  prolonged  nature  the  cut  edges  of 
the  abdominal  parietes  become  seriously  bruised  from 
traction  with  instruments  or  fingers.  The  resisting  power 
of  these  parts  is  therefore  markedly  lowered,  and  con- 
sequently they  are  very  liable  to  infection.  In  such  cir- 
cumstances more  or  less  sloughing  of  the  wound  may 
occur.  This  complication  is  particularly  likely  to  arise 
in  patients  whose  resisting  power  has  been  diminished  by 
the  cachexia  of  cancer  or  the  debility  of  old  age. 

Symptoms  and  signs. — Owing  to  the  severe  nature  of 
the  operation  in  these  cases,  it  must  be  expected  that  the 
patient's  pulse  and  temperature  will  be  raised,  but  with 
this  complication  the  temperature  will  be  higher  and  more 
irregular  than  the  mere  operation  gives  warrant  for.  Pain 
in  the  wound  may  be  complained  of,  and  the  wound,  when 
examined,  may  be  found  to  be  tender,  red,  and  swollen. 
In  other  cases,  however,  the  skin  looks  normal  in  spite 
of  the  serious  condition  of  the  underlying  tissues.  In 
a  few  days  it  breaks  down  along  its  whole  length  and 
a  fearfully  offensive  discharge  flows  from  it.  The  fascial 
and  muscular  edges  may  be  found  in  a  state  of  black 
sphacelus.  It  will  take  weeks  for  such  a  wound  to  granu- 
late up,  which  it  will  not  do  till  every  buried  suture  is 
discharged. 

Treatment.  — •  In  all  operations  performed  in  the  cir- 
cumstances and  under  the  conditions  just  detailed,  the 
edges  of  the  wound  must  be  dragged  on  as  little  as  possible 
and  the  operation  must  be  performed  as  speedily  as  its 
nature  permits  of.  The  plan,  devised  by  us  and  described 
on  p.  379,  of  covering  the  wound-edges  with  sheet  rubber, 
is  the  best  method  of  preventing  this  complication.  If 
sloughing  has  taken  place    the  wound   must  be  opened  up 


632  GYNAECOLOGICAL  SURGERY 

and  peroxide  of  hydrogen,  10  volumes,  should  be  used  to 
irrigate  it  frequently.  Gauze  soaked  in  the  same  drug  will 
be  found  the  most  useful  dressing  until  the  necrosed  tissue 
has  separated.  Fomentations  may  then  be  applied  for  a 
few  days,  and  when  the  area  is  clean  it  should  be  kept 
covered  with  lint  smeared  with  boric-acid  ointment.  When 
granulation  is  fairly  established,  dry  dressings  and  insuffla- 
tion with  aristol  should  be  substituted. 

If  the  abdominal  wound  has  suppurated  or  sloughed, 
it  will  be  found  to  heal  better  if  the  separated  edges  are 
drawn  together  as  much  as  possible.  This  cannot  be  done 
satisfactorily  by  means  of  strapping  applied  right  across 
the  wound,  for  the  pus  fouls  it  and  necessitates  its  frequent 
replacement,  a  process  which  very  soon  sets  up  an  ecze- 
matous  condition  of  the  skin.  The  object  in  view  may  be 
accomplished  quite  satisfactorily  by  sewing  a  tape  \  in. 
in  breadth  to  a  piece  of  strapping  5  in.  long  by  1  in. 
broad,  the  end  to  which  the  tape  is  sewn  having  been 
previously  overfolded  for  at  least  an  inch.  Two  or  three 
such  pieces  of  strapping,  as  may  be  required,  are  prepared 
for  each  side.  The  strapping  is  then  fixed  so  that  the  end 
to  which  the  tape  is  attached  lies  at  least  1  in.  from  the 
edge  of  the  wound.  After  the  wound  has  been  dressed, 
each  tape  is  drawn  taut  and  tied  to  the  corresponding 
tape  on  the  opposite  side,  the  edges  of  the  wound  being 
thus  approximated  (Fig.  386). 

The  scar  which  results  after  this  complication  is  always 
a  weak  one,  and  the  patient  must  wear  an  abdominal  belt 

Abdominal  Sinus 

Sinuses  can  be  roughly  divided  into  four  classes  : — 

1.  Superficial,  due  to  infection  of  fascial  sutures.  These 
are  usually  single,  but  on  occasion  a  series  may  occur, 
which  may  trouble  the  patient  for  three  or  four  years. 

2.  Those  connected  with  suppuration  along  the  con- 
tinuous peritoneal  suture.  These  are  multiple,  and  can 
be  made  to  communicate  with  each  other  by  a  probe. 


POSTOPERATIVE   COMPLICATIONS        633 

3.  Those  connected  with  the  ligatures  of  pedicles  in 
the  pelvis.  These  are  characterized  by  their  great  length, 
and  are  of  a  very  intractable  character.  They  are  usually 
single,  and  affect  the  lower  end  of  the  wound. 

4.  Those  occurring  along  the  site  of  an  old  drain-track, 
and  dependent  on  some  area  of  necrosed  tissue  or  chronic 
suppurating  surface,  such  as  an  imperfectly  removed  pyo- 


Fig.  386. — Method  of  applying  strapping  to  a 
suppurating  wound. 

salpinx.     They  not  infrequently  mark  the  site  of  an  old 
faecal  fistula. 

Treatment.  —  In  the  first  variety  it  is  sometimes  easy 
to  pass  down  a  director,  feel  the  suture,  and  then,  after 
cutting  it  with  a  pair  of  scissors,  remove  it.  At  other 
times,  although  it  can  be  felt,  it  is  very  difficult  to  remove. 
One  of  the  best  instruments  for  the  purpose  is  a  crochet- 
hook,  and  it  is  surprising  how  successful  this  little  instru- 
ment may  be  after  other  methods  have  failed.  Lastly,  in 
many  cases  the  ligature  or  suture  cannot  be  felt  at  all. 
In  these  cases,  unless  the  condition  is  causing  much  distress, 
the  patient  should  be  advised  to  wait  at  least  a  year  for 
natural  separation. 


634  GYNECOLOGICAL  SURGERY 

In  the  second  variety,  the  length  of  the  suture  involved 
renders  its  removal  difficult  unless  the  whole  length  of 
the  wound  be  opened  up,  though  on  occasions  it  is  pos- 
sible to  pull  it  up  with  a  crochet-hook  or  forceps  intro- 
duced through  one  of  the  sinuses.  It  is  better  in  most 
cases  to  wait  a  while  before  opening  up  the  wound, 
because  this  is  an  operation  involving  a  certain  amount 
of  danger. 

In  the  third  case,  if  the  ligature  cannot  be  pulled  up 
with  the  crochet-hook,  it  is  better  to  counsel  patience, 
in  the  hope  that  it  will  spontaneously  separate,  which  it 
invariably  does  after  a  considerable  time  (perhaps  some 
years).  Exceptionally  it  may  be  justifiable  to  cut  down 
upon  it.  This  is  often  an  operation  attended  by  great 
difficulty  and  distinct  dangers,  and  should  be  avoided  if 
possible. 

In  the  fourth  case  there  is,  as  a  rule,  no  definite  exciting 
cause  of  the  suppuration  which  is  removable  by  opera- 
tion. It  should  therefore  be  let  alone,  especially  in 
those  cases  where  a  faecal  fistula  has  previously  existed,  as 
there  would  be  a  great  danger  of  reopening  the  intestine, 
and  in  any  event  the  operation  is  most  unlikely  to  be 
successful. 

Fistula  of  the  Large  Intestine 

Cause. — The  large  intestine  may  be  torn  when  separating 
it  from  a  tumour  to  which  it  is  adherent.  If  the  tear  be 
not  recognized,  faecal  extravasation  takes  place,  and,  if  the 
patient  survives,  a  faecal  fistula  results. 

Faecal  fistulae  are  more  commonly  due  to  sloughing  of 
a  portion  of  the  intestinal  wall  which  has  been  damaged, 
but  not  opened,  at  the  time  of  the  operation. 

An  attenuated  rectal  wall  has  ruptured  as  the  result 
of  saline  injection  into  the  bowel. 

Lastly,  if  the  rent  in  the  wall  has  been  detected  and 
sewn  up,  a  fistula  may  appear  later  from  the  stitches  giving 
way.     The  majority  of  faecal  fistulae  occur  after  operations 


POSTOPERATIVE  COMPLICATIONS        635 

for  pyo-salpinx  or  tubo-ovarian  abscess  where  the  gut  was 
extremely  adherent. 

Treatment. — As  a  rule,  faecal  fistulae  close  spontaneously 
in  a  week  or  two,  although  they  may  be  as  long  as  twelve 
months  or  more  in  doing  so.  Beyond  keeping  the  parts 
clean,  no  treatment  is  indicated.  Before  any  operative 
attempt  is  made  to  close  the  fistula  it  should  be  given 
at  least  twelve  months  to  heal. 

It  is  our  experience  that,  no  matter  how  desperate  the 
case  appears  to  be,  the  patient  almost  invariably  recovers 
who  has  faecal  fistula. 

Fistula  of  the  Small  Intestine 

Fistulae  of  the  small  intestine  are  not  nearly  so  common 
as  those  of  the  large,  because  this  portion  of  the  gut  is 
much  less  commonly  adherent  to  pelvic  tumours.  On  the 
other  hand,  it  is  more  often  adherent  to  old  abdominal 
scars,  the  reopening  of  which  may  damage  it.  A  fistula 
of  the  small  intestine  is  a  more  serious  matter  than  one 
of  the  large,  because  there  is  not  the  same  tendency  to 
spontaneous  closure  ;  the  contents  are  liquid  and  very 
irritating  to  the  skin  ;  and,  lastly,  if  the  fistula  affects  the 
upper  portion  of  the  small  intestine,  a  progressive  emacia- 
tion results. 

Treatment. — If  a  wound  is  discovered  at  the  operation, 
it  must  be  carefully  sewn  up.  If  a  fistula  forms,  an  attempt 
must  be  made  to  close  it  as  soon  as  the  patient's  condition 
warrants  such  a  procedure.  Three  courses  are  open  to 
the  surgeon.  The  first  is  to  reopen  the  wound,  separate 
and  resect  the  involved  coil  of  intestine,  and  perform  an 
end-to-end  anastomosis.  The  second  course  is  to  form 
a  lateral  anastomosis  between  the  proximal  and  distal 
portions  of  the  involved  coil  through  a  separate  ab- 
dominal incision.  Thirdly,  if  the  fistula  is  very  small, 
the  edges  of  the  fistula  may  be  rawed  and  the  wound 
closed  by  sutures.  In  most  instances  the  first  course  is 
the  best. 


636  GYNECOLOGICAL  SURGERY 

Bursting 

Cause. — In  former  days,  when  the  abdominal  wound 
was  closed  with  one  layer  of  sutures,  it  occasionally  happened 
that  during  a  severe  fit  of  retching,  vomiting,  or  coughing 
the  wound  gave  way  and  the  intestines  protruded.  Now- 
adays, with  the  method  of  uniting  the  abdominal  wound 
in  three  layers,  this  accident  is  much  rarer,  but  it  still 
occasionally  happens,  though,  as  a  rule,  only  a  limited 
portion  of  the  wound  gives  way. 

Symptoms  and  signs.  —  Where  the  entire  wound  has 
burst,  the  patient  is  seized  with  a  sudden  sharp  pain, 
complains  of  something  having  given  way,  and  shows 
signs  of  collapse.  In  partial  bursting  no  complaint  may  be 
made  at  first,  though  later  increasing  rapidity  of  the  pulse 
and  pain  in  the  region  of  the  wound  will  be  noticed.  A 
valuable  sign  indicating  this  disaster  is  the  sudden  appear- 
ance of  blood  soaking  through  the  dressings  over  the  lower 
end  of  the  wound  at  a  period  when  ordinary  postoperative 
oozing  should  have  ceased.  On  lifting  up  the  bandage, 
more  or  less  of  the  intestine  is  found  protruding  through 
the  separated  edges  of  the  abdominal  incision.  If  the 
accident  is  discovered  early,  the  gut  merely  looks  dry  and 
is  patchily  covered  with  yellowish  lymph.  If  it  has  been 
long  protruded,  definite  peritonitis  will  be  present.  When 
tier  sutures  have  been  employed  it  sometimes  happens 
that  the  burst  does  not  affect  the  skin-layer.  In  such  a 
case  the  diagnosis  must  be  founded  upon  the  discovery 
of  a  resonant  tumidity  along  the  area  of  the  wound,  or, 
in  the  absence  of  this,  bursting  may  be  suspected  where, 
the  patient's  condition  being  unsatisfactory,  and  unusual 
pain  in  the  wound  being  complained  of,  a  steady  trickle 
of  blood,  or  a  copious  discharge  of  serum,  is  found  to  be 
escaping  between  the  skin-sutures.  The  possibility  of 
this  accident  should  always  be  borne  in  mind,  since 
in  most  of  the  cases  with  which  we  are  acquainted  its 
occurrence  was  at  first  overlooked. 


POSTOPERATIVE  COMPLICATIONS        637 

Prognosis. — -The  patient  generally  recovers  ;  rarely  acute 
general  peritonitis  supervenes  with  a  fatal  result. 

Treatment. — The  patient  should  be  anaesthetized,  and 
the  protruding  intestines,  having  been  carefully  cleaned 
with  warm  sterile  saline  solution,  should  be  replaced  and 
the  wound  closed  with  every  aseptic  precaution. 

Scar-Hernia 

Scar-hernia  has  become  a  less  common  complication 
than  it  was  before  the  method  of  closing  the  abdominal 
cavity  with  three  layers  of  suture  came  into  use.  There 
can  be  no  doubt  that  the  strength  of  a  median  abdominal 
scar  depends  entirely  on  the  proper  union  of  the  fascia. 
Scar-hernias  occur  with  increasing  frequency  towards  the 
pubis  ;  they  are  very  rare  above  the  umbilicus.  This  is  due 
to  the  fact  that  the  pressure  on  the  anterior  abdominal  wall 
increases  from  above  downwards  owing  to  the  weight  of 
the  intestines.  Thinning  of  the  abdominal  wall  is  also  a 
potent  factor,  but  it  must  be  combined  with  increased 
abdominal  pressure,  for  very  firm  scars  are  often  obtained 
in  patients  with  attenuated  parietes.  It  is  sometimes 
remarked  that  scar-hernias  more  frequently  affect  medium- 
sized  wounds  than  very  large  ones,  and  this  is  doubtless 
due  to  the  fact  that  the  large  incision  has  been  necessary 
to  remove  a  large  tumour,  with  the  result  that  the  abdominal 
tension  is  very  low  during  the  healing  of  the  scar. 

Increased  abdominal  tension  is  found  with  obesity, 
flatulence,  chronic  cough,  or  pregnancy,  and  where  one 
of  these  conditions  exists  before  an  abdominal  section,  it 
will  predispose  to  the  formation  of  a  scar-hernia. 

Causes. — Scar-hernia  may  be  due  to  either  of  the 
following  causes  : — 

1.  One  or  more  sutures  may  become  loose  shortly  after 
the  operation  owing  to  the  knots  giving  way,  the  suture 
tearing  out  or  breaking,  or,  if  of  catgut,  being  absorbed 
too  soon.  The  occurrence  of  such  a  hernia  is  soon  manifest 
as  a  swelling  under  the  skin,  resonant  on  percussion. 


638  GYNAECOLOGICAL  SURGERY 

2.  Suppuration  may  take  place  round  one  or  more 
stitches  soon  after  the  operation,  in  which  case  the  fascia 
in  their  neighbourhood,  not  having  had  time  to  unite,  may 
separate.  Again,  the  whole  wound  may  suppurate,  and 
the  fascial  edges  throughout  its  whole  length  separate, 
the  abdominal  contents,  after  the  skin  has  given  way, 
being  covered  merely  by  the  underlying  peritoneum.  Such 
wounds  take  many  weeks  to  cicatrize,  and  always  leave  an 
extremely  weak  and  papery  scar. 

3.  A  large  number  of  cases  of  scar-hernia  occur  at  the 
site  of  a  drain-track,  especially  when  this  is  situated,  as  it 
usually  is,  at  the  lower  end  of  the  wound. 

4.  The  scar  may  give  way  many  months  after  an  opera- 
tion, owing  to  the  rapid  abdominal  distension  associated 
with  pregnancy  or  ascites. 

5.  As  we  have  pointed  out  elsewhere,  women  who  have 
had  an  abdominal  section  should  not  undertake  any  duties 
necessitating  heavy  strain  for  several  months,  as  this  is 
liable  to  cause  the  scar  to  stretch.  It  is  among  the  poor, 
to  whom  this  advice  is  more  or  less  a  counsel  of  perfection, 
that  scar-hernias  are  most  common. 

6.  There  can  be  no  doubt  that  the  ill-fitting  corsets 
worn  by  women  of  the  lower  classes,  which  leave  the 
hypogastrium  destitute  of  all  support,  force  the  intestine 
downwards  and  raise  the  pressure  at  the  lower  point  of 
the  scar. 

Prophylaxis.  —  The  more  careful  the  surgeon  is  when 
suturing  the  abdominal  wound,  and  the  more  perfect  his 
asepsis,  the  less  risk  will  there  be  of  a  scar -hernia.  The 
fascial  layer  should  be  closed  with  interrupted  sutures, 
because  a  continuous  suture  has  the  great  disadvantage 
that  if  any  part  of  it  gives  way  the  whole  is  useless.  Silk 
is  to  be  preferred  to  catgut  for  suturing,  because  the  latter 
is  absorbed  and  its  knot  is  less  secure.  The  sutures  should 
be  sufficiently  numerous  to  leave  no  button-holes  between 
them,  and  especially  must  care  be  taken  to  ensure  that 
muscle    does   not   project   between   the    fascial   edges    and 


POSTOPERATIVE   COMPLICATIONS        639 

interfere  with  their  union.  The  silk  should  not  be  too 
thin,  No.  4  being  the  proper  size  to  use,  one  smaller  than 
this  increasing  the  liability  of  the  suture  to  cut  out. 

The  question  of  the  routine  use  of  belts  has  already 
been  discussed  (p.  570). 

Treatment.  —  The  anatomy  of  scar-hernias  has  an 
important  bearing  on  the  treatment.  There  are  certain 
cases  in  which  the  hernia  consists  of  a  diffuse  relaxation 
of  the  whole  breadth  of  the  abdominal  wall,  and  no  definite 
sac  is  present.  The  best  treatment  for  these  cases  is  a 
well-fitting  belt,  because  of  the  impossibility  by  operative 
measures  of  securing  fascial  edges  sufficiently  thick  to 
make  a  strong  scar.  If  an  operation  is  undertaken,  one 
of  two  methods  may  be  adopted  :  (a)  that  in  which  the 
fascial  layers  are  overfolded,  either  from  side  to  side  or 
from  above  downwards  ;  (b)  the  introduction  of  a  silver 
filigree  as  advised  by  Lawrie  McGavin. 

If  a  sac  is  present  it  may  consist  of  peritoneum  and 
skin,  or  of  skin  only,  according  to  whether  the  former 
layer  has  held  or  not.  In  the  latter  case  the  bowel  or 
omentum  will  always  be  found  extensively  adherent.  Scar- 
hernias  with  a  definite  sac  are  best  treated  by  operation, 
which  should  be  undertaken  as  soon  as  possible,  because 
it  is  then  much  easier.  In  a  few  cases,  when  the  patient 
is  very  feeble  and  the  hernia  very  large,  it  is  better  not  to 
operate  but  to  use  a  belt. 

Preparation  of  the  patient.— See  pp.  82-86. 

Instruments. — See  general  list,  p.  276. 

Operation,  i.  Opening  the  abdominal  cavity.  —  Very 
special  care  has  to  be  taken  when  opening  the  abdominal 
cavity  in  these  cases.  It  must  be  remembered  that  intestine 
or  omentum  is  very  likely  to  be  adherent  to  the  sac  of  the 
hernia,  and  to  cut  right  down  through  the  skin  covering 
it  is  only  to  court  disaster.  The  skin-incision  should  begin 
well  above  the  hernia,  and  should  be  carried  round  its 
lateral  limit  on  either  side  to  the  bottom  of  the  scar 
(Fig.    387).       The    fascia   is    next    incised   well   above    the 


640 


GYNAECOLOGICAL  SURGERY 


site  of  the  hernia,  and  the  peritoneum  is  seized  with 
two  pairs  of  pressure-forceps  and  incised  between  them 
(Fig.  388). 

ii.  Excision  of  the  hernial  sac.  —  The  operator  next 
passes  his  index  finger  through  the  hole  made  into  the 
peritoneal  cavity   (Fig.  389),  and,   using  it   as   a  guide  to 


Fig.  387. — Operation  for  ventral  hernia 
Making  the  skin  incision. 


ensure   that   the   intestines  be  not  wounded,   divides    the 
sac  at  its  outer  limit  on  one  side   (Fig.  390). 

iii.  Separation  of  adhesions. — The  sac  being  now  raised 
and  partially  turned  over,  it  may  be  seen  that  the  omentum 
or  intestines  are  adherent  to  it,  in  which  case  they  must 
be  separated,  ligatures  being  applied  where  necessary. 
It  is  better  to  resect  massive  portions  of  adherent  omentum 


POSTOPERATIVE   COMPLICATIONS        641 


Fig    389. — -Exploring  the  interior  of  the  sac. 


2   P 


642 


GYNECOLOGICAL  SURGERY 


by   clamping  them   with   pressure-forceps,    dividing   them, 
and  ligaturing  with  No.  4  silk  (Fig.  391). 

iv.  Removal  of  the  sac. — The  sac  is  now  completely 
excised  with  scissors,  after  which  the  raw  edges  of  the 
wound  are  trimmed  (Fig.  392)  until  the  edge  of  the  rectus 


Fig.  390. — Beginning  the  excision  of 
the  sac. 

muscle  on  each  side  is  clearly  defined  and  the  three  layers 
of  peritoneum,  fascia,  and  skin  are  properly  demarcated, 
v.  Closing  the  abdominal  wound. — The  wound  should 
be  closed  if  possible  in  three  layers,  after  the  manner 
described  elsewhere  (p.  285).  It  may,  however,  be  impos- 
sible to  suture  the  peritoneum  separately  owing  to  its  firm 
attachment  to  the  fascia,  in  which  case  only  two  layers  of 
sutures  can  be  used,  a  deep  interrupted  layer  of  silk  for 
the  peritoneum  and  fascia,  and  a  superficial  continuous 
layer  for  the  skin,  unless  clips  are  used.    Where  the  parietes 


POSTOPERATIVE  COMPLICATIONS       643 


are  very  attenuated  or  the  patient  very  stout,  a  series  of 
through-and -through  sutures  should  also  be  applied. 

Difficulties  and  dangers.  — •  Some  operations  for  scar- 
hernia  are  extremely  difficult  owing  to  the  dense  adhesions 
which  are  present. 
The  greatest  care 
must  be  exercised, 
especially  when 
beginning  to  in- 
cise the  sac,  lest 
the  bowel  be 
wounded.  It 
should  be  remem- 
bered that  inter- 
stitial prolonga- 
tions of  the  sac 
between  the  fascia 
and  muscle,  or 
fascia  and  skin, 
are  often  present, 
and  bowel  con- 
tained in  them 
may  be  easily 
wounded  whilst 
making  the  lateral 
incision.  Before 
closing  the  wound 
a  very  careful  ex- 
amination should 
be  made  of  the 
underlying  intes- 
tine,    in     case     a 

hole  should  have  been  made  in  it.  Death  has  followed 
failure  to  recognize  such  an  accident.  Finally,  when 
the  sac  is  very  large,  great  difficulty  may  be  found  in 
approximating  the  edges  of  the  wound,  and  through 
and-through  ^sutures    of  strong  silk,  applied  at    least  half 


Fig.  391. 


-Separating  adherent 
omentum. 


644 


GYNAECOLOGICAL  SURGERY 


an  inch  from  them,  may  have  to   be  used   to  sustain  the 
tension. 

Emphysema  of  the  Abdominal  Wall 

Causes — This    condition    may   be    due    to    air    let    into 
the   peritoneal  cavity  at  the  time  of   the  operation  being 


Fig.  392. — Trimming  the  edges 
of  the  wound. 


forced  thence  into  the  tissues  in  the  neighbourhood  of 
the  abdominal  incision.  It  may  also  be  due  to  entry  of 
atmospheric  air  between  the  skin-sutures  into  a  cavity 
that  has  been  left  between  the  peritoneum  and  the  fascia 
at  the  bottom  of  the  wound  ;    and  we  have  seen  it  occur 


POSTOPERATIVE  COMPLICATIONS       645 

where,  after  a  wound  in  the  bladder  had  been  sewn  up 
and  the  bladder  continuously  drained,  the  nurse  had  for- 
gotten to  keep  the  external  end  of  the  catheter  submerged 
in  water.  Lastly,  it  may  be  due  to  infection  with  the 
Bacillus  aerogenes  capsulatus. 

Symptoms  and  signs. — The  patient  may  complain  of 
slight  pain,  but,  as  a  rule,  nothing  is  noticed  till  the  wound 
is  dressed,  when  a  swelling  which  crackles  on  pressure  is 
seen  in  its  neighbourhood. 

Prognosis. — -In  the  commoner  forms  the  patient  recovers 
in  a  week  or  two  without  any  bad  symptoms.  When,  how- 
ever, the  condition  is  due  to  B.  aerogenes  capsulatus,  the 
outlook  is  serious,  the  wound  sloughing. 

Treatment. — No  treatment  is  required,  as  a  rule,  but 
if  there  is  evidence  that  infection  has  taken  place,  the 
swelling  must  be  incised  and  the  sloughing  tissues  irri- 
gated and  dressed  with  a  solution  of  peroxide  of  hydrogen, 
10  volumes. 

Foreign  Bodies  left  in  the  Abdomen 

The  object  most  frequently  left  in  the  abdomen  is  a 
sponge  or  swab.  This  accident  is  more  likely  to  happen 
when  the  operation  has  been  performed  for  some  sudden 
emergency.  In  similar  circumstances,  instruments,  large 
pieces  of  gauze  packing,  and  other  things  have  been  left 
behind.  Needles,  from  their  small  size,  are  easily  over- 
looked, while  drainage-tubes  have  not  infrequently  slipped 
back  into  the  abdominal  cavity  subsequently  to  the 
operation. 

A  study  of  recorded  cases  shows  that  although  the 
immediate  risks,  if  the  object  was  sterile,  are  not  great, 
the  final  results  of  this  accident  are  very  grave,  a  large 
number  terminating  fatally. 

Symptoms.  —  The  symptoms  are  usually  those  of  a 
definitely  local  pain  and  tenderness,  and  a  generally  un- 
satisfactory progress,  which  the  nature  of  the  case  does  not 
explain.     Not    infrequently  the  real  cause  has  been  finally 


646  GYNECOLOGICAL  SURGERY 

demonstrated  by  the  pointing  of  an  abscess  and  the  dis- 
charge of  the  foreign  body  through  the  abdominal  or  vaginal 
wound.  In  less  satisfactory  cases  the  sequestrated  object 
has  been  passed  by  the  bowel  or  retrieved  from  the  bladder. 
Cases  are  on  record  in  which  such  terminations  have  been 
postponed  for  many  months  or  years,  the  patient  mean- 
while being  in  continuous  suffering. 

Treatment.  —  This  accident  will  never  occur  if  the 
surgeon  himself  takes  the  trouble  not  only  to  count  all 
the  swabs  and  instruments  before  and  after  the  operation, 
but  also  to  make  out  a  list  of  them  beforehand,  which  can 
be  verified  prior  to  the  closing  of  the  peritoneal  cavity. 
In  hospital  practice  it  is  not  fair  to  burden  the  surgeon 
with  the  responsibility  of  actually  counting  the  swabs 
and  instruments,  and  such  duties  should  be  delegated  to 
some  responsible  person  such  as  the  theatre-sister  or  the 
house-surgeon,  but  the  surgeon  at  least  should  never 
forget  to  make  inquiry  concerning  them  before  suturing 
up  the  parietal  wound. 

Before  leaving  the  subject  there  are  two  or  three  points 
to  which  we  would  draw  attention.  It  is  obvious  that  the 
more  swabs  are  used  the  greater  will  be  the  danger  of 
their  being  left  behind  ;  the  operator  should  therefore 
endeavour  to  work  with  as  few  as  possible,  and  always  to 
begin  with  the  same  number.  If  the  operator  is  not  having 
his  swabs  washed,  he  should  use  the  original  ones  as  long 
as  possible  by  squeezing  out  the  blood  into  a  bowl ;  and 
if  it  is  necessary  to  open  a  second  packet,  this  should  contain 
the  same  number  as  the  first. 

Swabs  should  never  be  cut  in  halves,  this  being  one  of  the 
commonest  causes  of  the  accident  under  discussion.  And 
they  should  never  be  thrown  away  until  the  operation  is 
over  and  their  number  verified.  The  waste-hole  of  all  sinks 
in  operating-theatres  should  be  so  guarded  as  to  render  it 
impossible  for  a  swab  to  get  washed  down  a  waste-pipe. 

In  Caesarean  section,  if  a  hot  swab  is  put  into  the  cavity 
of  the  uterus  to  encourage  retraction,  and  this  chances  to 


POSTOPERATIVE  COMPLICATIONS        647 

slip  into  the  lower  uterine  segment  during  the  suturing  of 
the  wall,  it  may  not  be  missed  until  the  swabs  are  counted 
prior  to  closing  the  abdomen,  when  much  valuable  time 
may  be  wasted  in  hunting  for  it  in  the  peritoneal  cavity. 
If  the  swab  is  left  in  the  uterus  it  gives  rise  to  sepsis,  and 
the  operator,  having  previously  emptied  the  uterus  com- 
pletely of  placenta  and  membranes,  may  not  again  examine 
the  interior  of  this  organ,  and  the  nature  of  the  disaster 
may  only  be  disclosed  at  the  post-mortem. 

Many  a  swab  has  been  left  behind  owing  to  the  operator, 
after  they  had  been  counted,  having  reintroduced  one  as 
a  stitch-swab  to  keep  back  the  intestines  while  he  was 
securing  the  abdominal  wall. 

On  a  swab  or  instrument  being  missed,  the  surgeon, 
before  he  searches  the  abdominal  cavity,  should  have  the 
tumour  and  the  basin  containing  it  examined,  lest  it  be 
attached  to  the  one  or  contained  in  the  other.  In  addition, 
the  wrappings  surrounding  the  patient,  and  any  dirty 
towels  that  have  been  removed,  should  be  carefully  in- 
spected. The  nurse  at  times  may  report  that  a  swab  is 
missing  ;  the  surgeon  will  carefully  examine  the  abdominal 
cavity  and  fail  to  discover  it.  A  recount  will  show  the 
number  to  be  correct ;  the  nurse  has  made  a  mistake- 
In  such  a  case  the  surgeon  will  be  well  advised  not  to 
scold  the  nurse,  whatever  irritation  he  may  feel,  lest  on 
another  occasion  when  a  swab  is  really  missing  she  may 
fear  to  warn  him  of  the  accident. 

If  at  some  time  subsequent  to  the  operation  suspicion 
arises  that  a  metal  instrument  has  been  left  in  the  abdomen, 
the  question  can  be  settled  by  examination  with  X-rays. 

COMPLICATIONS   IN   THE    VAGINAL    WOUND 

VAGINAL     DISCHARGE 

Causes.  —  Troublesome  vaginal  discharge  following  a 
pelvic  operation  is  chiefly  seen  after  total  hysterectomy, 
and  is  due  to  suppuration  round  the  buried  ligatures  in 


M  GYNECOLOGICAL  SURGERY 

the  operation-site.  It  may  date  from  soon  after  the  opera- 
tion, or  may  only  appear  after  the  lapse  of  some  months. 
The  infected  ligatures  gradually  separate  and  the  discharge 
then  ceases,  but  the  process  may  take  some  while. 

A  very  intractable  form  of  discharge  is  often  seen  from 
the  uterus  after  operations  for  gonorrhceal  pyo-salpinx.  This 
subject  has  already  been  referred  to  (p.  489). 

Vaginal  sinuses  exuding  pus  frequently  follow  the 
removal  of  suppurating  tubes  or  ovaries  by  the  vaginal 
route,  and  may  originate  in  a  ligature  or  a  portion  of  the 
diseased  structure  that  has  been  left  behind — an  accident 
particularly  liable  to  follow  these  operations. 

Occasionally  curettage  may  initiate  a  chronic  purulent 
discharge,  whilst  the  sutures  used  in  plastic  vaginal  opera- 
tions, such  as  colporrhaphy,  may  be  responsible  for  the 
same  thing. 

Treatment. — Infected  sutures  after  total  hysterectomy 
may  be  left  to  separate  spontaneously,  as  a  rule,  the  vagina 
being  douched  twice  daily  with  boric-acid  solution.  Where, 
however,  the  discharge  is  profuse  and  distressing  to  the 
patient,  they  should  be  removed.  In  most  cases  they  are 
easily  accessible,  and  can  be  felt  and  seen  projecting  from 
the  granulation-covered  scar  in  the  vaginal  vault.  They 
can  usually  be  removed  without  an  anaesthetic  by  the  aid 
of  a  speculum  and  a  long  pair  of  scissors  and  forceps.  If 
the  patient  is  intolerant  of  manipulation,  an  anaesthetic 
should  be  given. 

Chronic  purulent  metritis  after  operations  for  gonor- 
rhceal pus -tubes  is  a  very  troublesome  condition.  Douching 
should  first  be  tried,  but,  if  the  discharge  persists,  thorough 
curettage  and  the  application  of  a  strong  chemical  anti- 
septic to  the  interior  of  the  organ  can  be  performed  if 
the  uterus  is  fairly  movable.  If  it  is  fixed,  or  if  previous 
curettage  has  failed,  as  it  often  does,  and  the  discharge  is 
a  serious  disabihty  to  the  patient,  removal  of  the  uterus  by 
the  abdominal  route  is  the  proper  treatment. 

A  vaginal  sinus   following  operation  on  the  adnexa  by 


POSTOPERATIVE  COMPLICATIONS       649 

posterior  colpotomy  had  better  be  allowed  a  good  chance 
of  clearing  up  of  itself.  If  it  refuses,  and  the  discharge 
is  making  the  patient  miserable,  the  condition  should  be 
dealt  with  by  abdominal  section  if  there  is  any  suspicion 
that  unremoved  portions  of  the  diseased  mass  are  main- 
taining the  condition.  If  a  ligature  is  held  to  be  the  cause, 
an  attempt  to  remove  it  by  enlarging  the  vaginal  sinus  is 
admissible. 

Purulent  discharges  following  minor  uterine  or  vag- 
inal operations  should  be  dealt  with  according  to  their 
cause — e.g.  a  repetition  of  the  curettage  or  the  removal 
of  an  irritating  suture. 

Prolapse  of  a  Fallopian  Tube 

Rarely  after  vaginal  hysterectomy  the  end  of  a  Fallo- 
pian tube  has  prolapsed  into  the  vagina  through  the  wound 
in  the  vaginal  vault,  and  on  the  wound  healing  has  become 
fixed  in  this  position.  The  slight  hydrorrhcea  which  may 
result  has  led  to  an  examination  and  diagnosis  of  granu- 
lation tissue  or  carcinoma.  The  condition  requires  no 
treatment. 


CHAPTER    XXXVIII 
POSTOPERATIVE    COMPLICATIONS  (Continued) 

PULMONARY    COMPLICATIONS 

After  operation  the  following  diseases  of  the  lungs  and 
pleura  may  occur,  namely,  bronchitis,  broncho-pneumonia, 
lobar  pneumonia,  septic  pneumonia,  pleurisy,  embolism,  etc. 

Bronchitis 

This  may  be,  and  very  often  is,  due  to  the  ether  adminis- 
tered at  the  operation,  and  is  then  known  as  ether-bron- 
chitis. It  is  not  always  due  to  ether,  however,  since  it 
often  comes  on  three  or  four  days  after  the  operation, 
whereas  ether-bronchitis  supervenes  at  once.  When  not 
due  to  ether  it  is  in  some  cases  possibly  caused  by  undue 
exposure  during  the  operation.  In  most  cases  the  patients 
have  already  been  subject  to  bronchitis.  It  is  sometimes 
due  to  infection  from  the  mouth-pieces  or  bags  of  the 
anaesthetic  apparatus.  All  competent  anaesthetists  nowa- 
days wash  the  face-piece  and  ether-bag  as  a  routine  prac- 
tice, but  where  a  separate  bag  is  used  for  the  preliminary 
administration  of  gas  there  is  sometimes  a  risk  that  the 
anaesthetist  may  forget  to  wash  it. 

Broncho-Pneumonia 

This  is  either  primary  or  secondary  to  a  spreading 
bronchitis.  It  is  characterized  by  rapid  breathing,  cyanosis, 
and  absence  of  air-entrance  to  the  bases  of  the  lungs,  over 
which  numerous  slight  rales  are  heard.  Marked  inspira- 
tory retraction  of  the  lower  intercostal  spaces  is  noticed. 
The  prognosis  is  bad. 

650 


POSTOPERATIVE  COMPLICATIONS        651 

Lobar  Pneumonia 

Lobar  pneumonia  sometimes  complicates  recovery,  and 
the  classical  signs  and  symptoms  are  present.  The  prog- 
nosis differs  in  no  way  from  that  of  pneumonia  in  other 
circumstances. 

Septic  Pneumonia 

This  is  a  blood-borne  infection  of  the  lung,  and  is  usually 
the  result  of  breaking-down  thrombi  in  some  of  the  pelvic 
veins.  The  disease  begins  with  rapid  breathing  and  pleural 
pain,  and  in  most  cases  a  pleural  effusion  rapidly  forms, 
at  times  purulent  in  nature.  Elsewhere  multiple  slight  dry 
rales  are  heard.  At  first  there  is  no  expectoration,  whilst 
later  a  little  rusty  sputum  may  be  coughed  up.  The 
prognosis  is  very  bad  indeed. 

Gangrene  of  the  Lung 

This  rare  complication  is  due  either  to  a  septic  embolus 
or  to  some  food  being  inhaled  as  a  result  of  vomiting  under 
the  anaesthetic. 

Acute  Phthisis 

Rarely,  acute  phthisis  will  follow  an  operation.  We 
have  seen  one  such  case.  It  is  nearly  always  due  to  qui- 
escent disease  becoming  acute  from  the  irritation  of  the 
anaesthetic . 

Pleurisy 

On  examination  of  the  records  of  a  number  of  cases  of 
postoperative  pulmonary  troubles,  pleurisy  is  found  to 
form  an  appreciable  percentage  of  the  total.  It  may  be 
either  primary,  or  due  to  extension  from  a  lobar  or  septic 
pneumonia.     Effusion  may  or  may  not  occur. 

Pulmonary  Embolism 

Pulmonary  embolism  is  the  most  tragic  disaster  of  all 
postoperative    complications.      It    most    commonly    occurs 


652  GYNAECOLOGICAL  SURGERY 

from  the  tenth  day  onwards,  and  in  most  cases  follows 
upon  a  convalescence  which  till  then  had  been  regarded 
as  satisfactory.  We  have  found  on  a  careful  perusal  of 
the  temperatures  in  these  patients  that  in  almost  all  cases 
a  little  unexplained  fever  preceded  the  disaster  and  that 
the  pulse-rate  was  a  little  fast.  It  is  a  remarkable  fact 
that  embolism  rarely  follows  on  a  definite  attack  of  phle- 
bitis and  thrombosis,  probably  because  in  these  cases  the 
clot  is  so  firmly  attached  to  the  vein-wall  that  it  cannot 
readily  shift. 

The  postoperative  embolus  is  probably  derived  from  a 
vein  in  which  thrombosis  has  occurred  from  so  slight  a 
degree  of  inflammation  as  to  leave  the  wall  almost  intact 
and  the  clot  very  loosely  attached.  It  is  this  phlebitis 
which  probably  gives  rise  to  the  trifling  fever  and  increased 
pulse-rate  we  have  noted.  Such  slight  phlebitis  and  throm- 
bosis are  particularly  apt  to  occur  in  patients  who  have 
been  bleeding  seriously  for  some  time  prior  to  the  operation, 
as,  for  instance,  in  exsanguinated  myoma  cases.  The  actual 
catastrophe  is  always  precipitated  by  some  movement, 
such  as  sitting  up  in  bed  or  endeavouring  to  rise  from  a 
chair  ;  it  thus  commonly  affects  patients  just  about  to 
leave  the  hospital  or  nursing-home.  The  patient  is  seized 
with  great  and  sudden  pain  in  the  chest,  has  a  sensation 
of  choking,  and  commences  to  struggle  violently  for  breath. 
She  quickly  becomes  blue  in  the  face,  unconsciousness 
rapidly  supervenes,  and  respiration  stops,  but,  though  the 
pulse  is  so  fast  and  feeble  that  it  cannot  be  counted,  the 
heart  usually  continues  to  beat  for  some  minutes  longer. 
When  the  embolus  is  so  large  that  it  entirely  blocks  the 
pulmonary  circulation,  the  heart  may  immediately  stop, 
in  which  case  there  is  sudden  pallor  instead  of  cyanosis, 
and  the  patient  may  be  said  to  die  instantaneously.  We 
have,  however,  seen  cases  in  which,  with  sudden  pain  and 
dyspnoea,  a  large  area  of  consolidation  of  the  lung  rapidly 
appeared ;  and  we  regard  these  as  examples  of  pulmonary 
embolism  on  a  scale  not  incompatible  with  life. 


POSTOPERATIVE  COMPLICATIONS        653 

Treatment  of  pulmonary  complications. — In  bronchitis 
and  broncho-pneumonia  secondary  to  it,  the  patient  should 
at  once  be  placed  in  a  steam-tent  and  given  some  such 
mixture  as  the  following,  which  we  have  found  very 
useful  : — ■ 

jy    Sodse  bicarb,  gr.  xx. 

Spirit,  ammon.  aromat.   Tl\xv. 
Spirit,  chlorof.  H\x. 
Aq.  camph.  ad  gi. 
To  be  taken  every  four  hours. 

The  treatment  of  lobar  pneumonia  should  be  carried 
out  on  the  recognized  lines.  Septic  pneumonia  must  be 
treated  by  stimulants  and  aspiration  of  the  thorax  if  neces- 
sary, and  the  injection  of  a  suitable  antitoxic  serum  or 
vaccine.  Pleurisy  and  acute  phthisis  require  the  usual 
treatment. 

In  pulmonary  embolism  the  patient  must  be  placed 
on  her  back,  given  stimulants  such  as  brandy,  ether,  and 
strychnine  by  the  mouth  or  hypodermically,  and  if  breath- 
ing ceases  artificial  respiration  may  be  performed  so  long 
as  the  heart  continues  to  beat.  If  oxygen  is  available  it 
should  certainly  be  administered,  and  venesection  may  be 
tried  if  there  is  marked  cyanosis.  If  the  patient  recovers, 
morphia  should  be  given  later  to  quiet  the  circulation. 

As  regards  prevention,  aseptic  operative  technique  is 
the  most  important.  Where  a  patient  continuously  exhibits 
a  pulse-rate  and  temperature  slightly  above  the  normal 
without  any  ascertainable  local  cause,  subacute  pelvic 
phlebitis  and  thrombosis  should  be  suspected.  Such 
patients,  especially  if  anaemic,  should  be  kept  very  quiet 
and  not  allowed  to  get  out  of  bed  or  make  any  unnecessary 
exertion.  But  even  with  the  greatest  care  this  terrible 
catastrophe  is  not  altogether  to  be  avoided. 

FAT-EMBOLISM 

This  as  a  complication  after  abdominal  section  is  very 
rare,  and  we  have  never  seen  a  case.     The  symptoms  and 


654  GYNECOLOGICAL  SURGERY 

signs  described  as  attending  such  a  condition  are  cardiac 
distress  and  jaundice,  followed  by  hyperesthesia  of  the 
skin  on  the  abdomen  and  legs,  involuntary  spasms  of 
the  face-muscles,  coma,  and  pleurisy  with  effusion.  On  the 
fifth  day  following  the  operation,  fat  appeared  in  the  urine, 
and  on  the  seventh  day  in  the  blood.  The  cardiac  distress 
disappeared  in  forty-eight  hours,  and  the  fat  from  the 
urine  on  the  fourteenth  day. 

BLADDER    COMPLICATIONS 

The  following  complications  may  occur,  namely,  reten- 
tion, painful  micturition,  cystitis,  suppression,  incontinence, 
fistulae. 

Retention 

Causes. — -Retention  is  due  to  inhibition  of  the  micturi- 
tion centre  in  the  lumbar  region  of  the  spinal  cord,  caused 
by  the  shock  following  severe  operations,  or  reflexly,  from 
the  anticipation  of  painful  micturition,  especially  after 
operations  dealing  with  the  parts  in  the  neighbourhood 
of  the  vaginal  outlet. 

Retention  may  also  be  due  to  the  unaccustomed  posi- 
tion ;  and  further,  if  the  patient  has  been  catheterized  once 
or  twice,  she  may,  so  to  speak,  get  used  to  the  procedure 
and  be  unable  to  pass  water  normally.  In  cases  where  it 
has  been  necessary  to  pack  the  vagina,  the  pressure  of  the 
tampons  may  be  so  great  that  the  urethra  is'  thereby 
occluded.  Lastly,  in  those  operations  where  the  bladder 
has  to  be  extensively  separated  and  its  relations  much 
altered,  as  in  the  radical  abdominal  operation  for  carcinoma 
of  the  cervix,  absolute  retention,  as  a  rule,  occurs  for  several 
days,  and  partial  retention  for  a  week  or  two  longer. 

Treatment. — If  retention  occurs  after  minor  opera- 
tions, hot  fomentations  to  the  abdomen,  placing  a  bed-pan 
containing  very  hot  water  under  the  patient  so  that  steam 
shall  bathe  the  parts,  bathing  the  vulva  with  warm  water, 
a  smart  purge,  or  a  dose  of  opium  may  succeed  in  different 


POSTOPERATIVE   COMPLICATIONS        655 

cases.  In  the  event  of  their  failure,  the  catheter  must  be 
used.  If  retention  occurs  after  major  operations,  the 
catheter  must  be  used  at  once,  because  a  distended  bladder 
may  injuriously  affect  the  operation-site.  It  is  to  be  re- 
membered that  a  patient  may  be  able  to  pass  some  urine 
naturally,  and  yet  not  empty  her  bladder,  and  that  where 
the  relations  of  the  bladder  have  been  much  altered  by 
the  operation,  it  is  possible  to  get  considerable  distension 
of  the  viscus  without  any  tumour  being  palpable  through 
the  abdominal  wall. 

Painful  Micturition 

This  may  be  due  to  the  urine  flowing  over  the  injured 
parts  after  operations  upon  or  in  the  neighbourhood  of  the 
urethra.  It  may  also  accompany  perivesical  inflammation 
either  in  the  peritoneum  or  the  connective  tissue.  Lastly, 
it  may  be  due  to  cystitis.  It  is  not  an  uncommon  occurrence 
for  pain  on  micturition  to  develop  about  the  commence- 
ment of  the  second  week  after  abdominal  section,  cystitis 
or  pericystitis  being  in  most  cases  the  cause. 

Cystitis 

Two  forms  of  cystitis  may  appear  after  abdominal 
section.     One  is  common,  the  other  rare. 

The  common  variety  is  an  inflammation  of  the  bladder- 
wall  due  to  infection  from  the  site  of  the  operation  with 
Bacillus  coli  communis.  The  patient  complains  of  pain 
about  the  commencement  of  the  second  week,  and  an  ex- 
amination of  the  urine  shows  it  to  be  acid  and  to  contain  a 
little  pus.  Probably,  at  first,  the  mucous  coat  of  the  blad- 
der escapes,  and  so  the  urine  is  unaffected  ;  subsequently, 
when  it  inflames,  pus  appears  in  an  acid  urine.  More  rarely 
the  primary  infection  may  be  staphylococcal,  in  which 
case  the  urine  is  alkaline  from  the  first ;  or,  beginning  as  a 
colon  infection,  the  cystitis  may  terminate  as  a  staphylo- 
coccic, in  which  case  the  urine  is  first  acid  and  then 
alkaline, 


656  GYNECOLOGICAL  SURGERY 

The  less  common  variety  is  due  to  careless  catheteriza- 
tion, in  which  case  the  urine  soon  becomes  alkaline  and 
ammoniacal. 

Treatment. — If  the  urine  remains  acid,  salol  in  15-grain 
doses,  taken  three  times  daily,  or  urotropin  in  10-grain 
doses,  acts  as  a  specific. 

If  the  urine  becomes  alkaline  and  ammoniacal,  the 
bladder  should  be  washed  out  twice  daily.  The  method  of 
doing  this  is  as  follows  :  Six  ounces  of  boric-acid  solution 
(a  drachm  to  the  pint),  at  a  temperature  of  ioo°,  is  run 
into  the  bladder  by  means  of  a  soft  rubber  catheter  with 
a  glass  funnel  attached.  After  a  short  interval  the  fluid 
is  allowed  to  escape  by  lowering  the  funnel,  and  this  is 
repeated  until  the  fluid  comes  away  clear. 

For  intractable  cases  the  bladder  may  be  washed  out 
with  a  1  per  cent,  solution  of  protargol  once  a  day,  and 
we  have  seen  success  follow  the  use  of  a  vaccine  prepared 
from  an  organism  isolated  from  the  urine. 

Suppression  of  Urine 

This  condition  is  due  either  to  ureteral  obstruction  or 
to  renal  shock.  In  obstruction,  both  ureters  may  be  included 
in  ligatures  or  clamps ;  one  ureter  may  be  caught  and  the 
opposite  kidney  fail  from  sympathetic  shock,  or  the  ureter 
involved  may  be  the  only  one  that  is  functional.  This 
accident,  unless  care  be  taken,  is  especially  liable  to  occur 
in  vaginal  hysterectomy,  in  abdominal  total  hysterectomy, 
during  the  enucleation  of  broad-ligament  tumours,  and  in 
the  removal  of  cervical  myomata. 

If  the  only  functional  ureter  or  both  ureters  are  occkfded , 
no  urine  at  all  will  be  passed,  nor  will  any  be  passed  in 
suppression  due  to  primary  shock. 

In  the  case   of  sympathetic  shock  there  is  a  gradual 
diminution  in  the   quantity   of   urine   passed,   blood  may 
appear,    and    eventually    there    is    complete    suppression 
These  cases  are  due  to  an  acute  toxic  degeneration  of  the 
kidney.     The  course  of  such  cases  is  very  characteristic. 


POSTOPERATIVE  COMPLICATIONS        657 

For  several  days  there  may  be  no  symptoms  at  all — the 
so-called  tolerant  period  ;  this  is  followed  by  a  condition 
of  high  mental  distress  and  nervous  irritability,  in  which 
the  patient  may  complain  of  strange  and  terrible  sensa- 
tions ;  the  pulse  is  much  quickened  though  the  tempera- 
ture may  be  subnormal.  Finally,  the  patient  becomes 
comatose  and  dies. 

Treatment.  ■ — ■  The  urine,  after  all  operations  in  the 
neighbourhood  of  the  ureters,  should  be  examined.  Clear 
urine  shows  that  in  all  probability  the  ureters  are  intact. 
The  quantity  of  urine  should  always  be  measured  after 
such  operations,  although  it  must  be  remembered  that 
the  amount  excreted  for  the  first  two  days  following  an 
operation  may  be  very  much  less  than  normal. 

Clamp  forceps  which  have  been  left  on  the  broad  liga- 
ments in  vaginal  hysterectomy  should  be  removed  at  the 
end  of  twenty-four  hours  in  case  they  include  the  ureter. 
If  the  ureter  is  obstructed  the  surgeon  must,  of  course,  at 
once  adopt  such  measures  as  the  case  indicates.  The 
abdomen  has  been  opened  ten  days  after  an  operation,  and 
the  ureter  freed  from  the  ligature  in  which  it  had  been 
included,  with  successful  results. 

When  the  condition  is  due  to  "  shock,"  or  in  the  obstruc- 
tive cases  after  the  ureter  has  been  freed,  the  ordinary 
measures  for  suppression  must  be  adopted.  The  patient 
should  be  given  large  draughts  of  water,  and  copious 
injections  of  saline  solution  by  the  bowel  may  be  tried. 
If  these  methods  fail  to  stimulate  the  kidney,  the  loins 
should  be  dry-cupped,  the  patient  placed  in  a  hot-air 
bath,  and  pilocarpin,  gr.  |,  administered  hypodermically 
every  four  hours.  In  addition,  an  injection  of  saline  solu- 
tion into  the  veins  or  under  the  breasts  until  an  improve- 
ment is  shown  may  be  tried. 

Lastly,   when  these  measures  have  failed,   the  kidney 
may  be  exposed  from  the  loin  and  nephrostomy  or  decap- 
sulation performed,  according  to  whether  the  suppression 
is  due  to  obstruction  or  renal  "  shock," 
2Q 


658  GYNAECOLOGICAL   SURGERY 

Incontinence 

Incontinence  of  urine  is  most  usually  due  to  retention, 
but  it  may  also  be  caused  by  a  wounded  bladder  or  an  injury 
to  the  ureters. 

If  retention  is  the  cause,  then  there  must  have  been 
carelessness  on  the  part  of  the  nurse  in  not  recognizing 
or  reporting  the  retention,  and  on  the  part  of  the  surgeon 
in  not  making  himself  acquainted  with  the  quantity  of 
urine  that  was  being  passed. 

The  bladder  is  most  commonly  wounded  in  operations 
on  the  anterior  vaginal  wall,  such  as  colporrhaphy,  enuclea- 
tion of  a  cyst  or  solid  tumour,  and  during  a  vaginal  or 
total  abdominal  hysterectomy.  This  accident  should,  of 
course,  be  detected  at  the  time  of  the  operation  and  the 
rent  sewn  up,  but  the  stitches  may  give  way,  leading  to 
incontinence  a  few  days  later. 

A  ureter  may  be  wounded  in  an  abdominal  or  vaginal 
hysterectomy  or  other  operation  in  its  immediate  neigh- 
bourhood in  which  the  vagina  is  opened.  In  this  case  its 
cut  end  may  become  engrafted  in  the  vaginal  wound,  and 
the  urine  will  then  continuously  trickle  out  of  the  vagina. 
The  same  result  occurs  in  the  event  of  an  unsuccessful 
uretero-vesical  anastomosis.  In  all  cases  of  ureteral  fistula 
there  is  a  great  likelihood  of  sepsis  travelling  up  the  ureter 
and  setting  up  pyelo-nephritis. 

Treatment.  —  If  the  incontinence  is  due  to  retention, 
the  treatment  is  obvious.  If  to  injury  of  the  bladder,  a 
catheter  should  be  tied  in  this  organ,  which  should  then 
be  washed  out  daily  with  a  solution  of  boric  acid.  If  the 
bladder  and  fistula  can  be  kept  aseptic,  the  latter  after  a 
while  may  heal ;  if  it  does  not,  it  must  be  closed  in  one 
of  the  ways  described  at  p.  145. 

When  the  ureter  has  been  divided,  the  treatment 
consists  (a)  in  opening  the  abdomen,  freeing  the  ureter,  and 
transplanting  it  into  the  bladder  (p.  540)  ;  (b)  in  attempting 
a  plastic  operation  through  the  vagina  to  unite  the  ureter 


POSTOPERATIVE  COMPLICATIONS       659 

and  bladder  ;  or  (c)  in  removing  the  kidney.  The  last 
measure  should  never  be  performed  until  ample  time  for 
spontaneous  closure  has  elapsed.  Further,  it  is  absolutely 
necessary  to  be  sure  that  the  opposite  kidney  is  healthy. 
The  operator,  again,  must  be  most  careful,  by  a  cystoscopic 
examination,  to  ascertain  which  ureter  is  damaged,  other- 
wise he  may  have  the  mortification  of  removing  the  kidney 
which  is  connected  with  the  healthy  ureter.  If  the  operator 
cannot  obtain  a  cystoscope,  and  in  any  case  as  a  control  of 
the  accuracy  of  the  cystoscopic  examination,  the  following 
plan,  practised  by  us,  will  be  found  very  useful  :  The 
suspected  kidney  having  been  exposed  in  the  loin,  10  c.c. 
of  a  strong  solution  of  methylene  blue  is  injected  into  its 
pelvis  with  a  serum  syringe.  The  kidney  is  then  returned 
within  the  wound,  which  is  temporarily  plugged,  and  the 
vagina  is  plugged  with  a  swab.  In  about  15  minutes  the 
bladder  is  catheterized,  and  the  tint  of  the  withdrawn 
urine  is  compared  with  that  of  the  fluid  squeezed  from 
the  vaginal  swab.  If  the  kidney  exposed  corresponds  to 
the  faulty  ureter,  the  urine  in  the  vaginal  swab  will  be 
blue,  while  that  drawn  from  the  bladder  will  be  normal 
in  colour.  The  removal  of  the  kidney  is  then  proceeded 
with. 

Vesicoabdominal   and   Uretero-Abdominal   Fistula 

Where  the  bladder  or  the  ureter  has  been  injured  in 
the  course  of  an  abdominal  operation  and  the  wound  has 
been  drained,  a  fistulous  track  opening  at  its  lower  end 
may  subsequently  form,  if  the  patient  escapes  the  imme- 
diate danger  of  general  peritonitis. 

_,  The  treatment,  if  the  fistula  is  quite  recent  and  un- 
associated  with  septic  signs,  would  be  to  reopen  the  wound 
and  either  close  the  wound  in  the  bladder  or  implant  the 
ureter.  Where,  on  the  other  hand,  the  fistula  is  some 
weeks  old,  or  is  the  seat  of  suppuration,  it  had  better  be 
treated  expectantly.  Many  fistulas  so  treated  close  spon- 
taneously after  a  while. 


660  GYNAECOLOGICAL  SURGERY 

KIDNEY    COMPLICATIONS 

Acute  Nephritis 

After  an  operation  on  the  pelvic  organs,  acute  nephritis 
may  complicate  the  convalescence.  It  is  in  some  cases, 
perhaps,  due  to  the  anaesthetic,  in  others  to  sepsis.  The 
usual  symptoms  and  signs  will  be  present,  the  patient 
complaining  of  headache,  dimness  of  vision,  and  nausea  ; 
the  temperature  will  be  raised  to  1020  or  over  ;  the  pulse- 
rate  will  be  increased  ;  there  will  be  oedema  of  the  body, 
more  especially  in  the  hands,  face,  and  feet  ;  and  an 
examination  of  the  urine  will  disclose  a  large  quantity  of 
albumin,  hyaline  and  cellular  casts,  while  the  amount 
of  the  secretion  will  be  diminished. 

Treatment.  —  The  patient  must  be  treated  on  the 
usual  lines  of  purgation  and  diaphoresis.  The  diet  must 
be  strictly  limited  to  milk,  and  a  large  quantity  of  water 
should  be  drunk. 

Pyelitis,    Pyelo-Nephritis 

Causes. — Pyelitis  and  pyelo-nephritis  are  due  to  an 
ascending  infection  along  the  ureter  following  cystitis, 
when  they  may  be  bilateral,  to  suppuration  in  the  neigh- 
bourhood of  a  ureter  or  some  damage  to  a  ureter  or  to 
the  bladder  in  its  neighbourhood,  when  they  are  unilateral. 
The  ureter  may  be  ligatured  or  clamped  during  the  per- 
formance of  a  straightforward  hysterectomy,  either  abdo- 
minal or  vaginal.  It  is  more  likely  to  be  injured  during 
the  enucleation  of  a  broad-ligament  cyst  or  the  removal 
of  a  broad-ligament  myoma,  and  most  likely  of  all  during 
the  radical  operation  for  carcinoma  of  the  cervix.  More 
rarely,  the  ureter  may  be  compressed  by  an  inflammatory 
exudation  in  the  broad  ligament  following  some  operation 
which  has  interfered  with  that  structure. 

We  have  also  seen  a  case  in  which  the  disease  was  due 
to  the  compression  of  the  lower  end  of  the  ureter  by  blood 
which   had   oozed   from   some   small   vessel   in   the   broad 


POSTOPERATIVE   COMPLICATIONS        661 

ligament  after  the  removal  of  a  broad-ligament  myoma, 
and  had  then  clotted  round  the  ureter.  This,  as  far  as  we 
know,  is  the  only  case  of  its  kind  ever  reported.  The 
presence  of  a  ureteral  fistula  in  most  cases  eventually 
results  in  pyelitis  and  pyelo-nephritis. 

Symptoms.  —  The  patient  complains  of  pain  in  the 
region  of  the  affected  kidney,  and  perhaps  along  the  course 
of  the  ureter.  This  pain  may  be  more  or  less  continuous 
or  colicky  in  nature.  It  is  often  so  severe  that  morphia 
has  to  be  administered.  The  general  condition  also  denotes 
that  fever  is  present. 

Signs. — The  kidney  is  found  to  be  enlarged  and  tender. 
The  quantity  of  urine  is,  as  a  rule,  diminished,  and  a  large 
amount  of  albumin  will  be  found  in  it.  The  degree  of 
pyuria  will  depend  upon  whether  the  disease  mostly  affects 
the  pelvis  or  the  substance  of  the  kidney.  In  the  first 
case  there  may  be  sufficient  pus  to  form  a  well-marked 
sediment  in  the  urine-glass  ;  in  the  second  case  the  pus 
may  only  just  cloud  the  urine,  and  its  presence  will  be 
determined  by  microscopical  examination.  A  bacterio- 
logical examination  usually  reveals  a  bacilluria  due  to  B. 
coli  communis.  Again,  the  amount  of  pus  present  will  de- 
pend upon  whether  the  ureter  is  compressed  or  not,  and 
may  vary  from  day  to  day  accordingly.  The  temperature 
is,  as  a  rule,  fairly  high,  varying  between  ioi°  and  1030, 
more  especially  if  much  pyelitis  is  present.  If  the  kidney 
substance  is  more  particularly  affected,  the  temperature 
may  keep  at  a  lower  level.  The  pulse-rate  will  be  increased 
and  the  tongue  dry  and  brown.     Rigors  may  occur. 

In  the  case,  previously  referred  to,  due  to  a  blood-clot, 
an  examination  under  an  anaesthetic  revealed  a  hard 
swelling  in  the  neighbourhood  of  the  left  ureter,  about  the 
size  of  an  unshelled  walnut,  spreading  upwards  along  the 
course  of  the  ureter  and  giving  the  sensation  of  a  thickened 
pipe.  On  cystoscopic  examination  the  left  ureteral  orifice 
and  the  bladder  in  its  neighbourhood  showed  great  ecchy- 
mosis.     The  orifice  of  the  ureter  was  also  narrowed  and  no 


662  GYNECOLOGICAL  SURGERY 

urine  was  escaping  from  it  during  the  examination,  although 
some  obviously  did  during  the  twenty-four  hours,  from 
the  large  quantity  of  albumin  present  and  the  condition 
of  the  left  kidney. 

Prognosis.  —  The  prognosis  depends  a  good  deal  upon 
the  cause.  In  cases  of  cystitis,  when  the  bladder  trouble 
is  cured  the  disease  of  the  kidney  may  settle  down.  Where 
the  ureter  has  been  damaged  the  prognosis  is  more  grave. 

Treatment. —  If  the  condition  is  due  to  a  cystitis,  the 
patient  may  be  treated  on  the  lines  indicated  at  p.  655. 
If  due  to  pressure  from  inflammatory  exudation  or  blood- 
clot,  time  must  be  given  for  these  to  be  absorbed.  If  pus 
forms  in  the  broad  ligament,  it  should  be  evacuated  by 
the  vaginal  route  and  the  area  drained. 

If  the  pyelo-nephritis  is  found  to  be  due  to  B.  coli  infec- 
tion, large  doses  of  citrate  and  acetate  of  potash  or  sodium 
(gr.  xxx  every  three  hours)  will  sometimes  quickly  relieve 
the  condition.  Treatment  by  vaccine  has  often  proved 
successful,  and  in  one  case  of  ours  complicating  pregnancy 
we  cured  the  disease  by  washing  out  the  renal  pelvis  through 
a  ureteral  catheter — a  recent  method  of  treatment  that  has 
proved  successful  in  the  hands  of  others. 

If  the  kidney  disease  becomes  worse,  the  question  of 
nephrectomy,  or  at  any  rate  of  nephrotomy,  will  have  to 
be  seriously  considered.  Before  the  kidney  is  operated 
upon,  however,  it  is  most  essential  that  a  cystoscopic 
examination  should  be  made  in  order  that  the  condition 
of  the  urine  escaping  from  the  ureters  may  be  observed, 
as  it  is  not  always  easy  to  ascertain  the  state  of  the  kidney 
from  palpation,  and  it  may  be  that  both  kidneys  are 
involved. 

Hydronephrosis,  Pyo-Nephrosis 

Hydro-nephrosis  is  due  to  a  partial  blocking  of  the 
ureter  from  growth,  ligation,  or  compression  of  inflamma- 
tory products.  The  blockage  is  probably  not  complete, 
but  intermittent,  since,  if  the  ureter  is  completely  clamped 


POSTOPERATIVE  COMPLICATIONS        663 

or  ligated,  atrophy  of  the  kidney  results.  The  patient 
complains  of  pain  in  the  affected  kidney  and  along  the 
course  of  the  ureter  of  that  side ;  there  is  an  alteration 
in  the  quantity  of  urine,  so  that  at  one  time  the  amount 
will  be  diminished,  and  at  another  markedly  increased 
owing  to  the  escape  of  urine  from  the  distended  kidney. 
If  a  local  examination  of  the  kidney  is  made  after  the 
passage  of  the  increased  quantity  of  urine,  its  size  will  be 
found  to  be  much  diminished,  and  the  patient  will  suffer 
less  pain  and  tenderness.  As  time  goes  on,  if  the  condi- 
tion is  not  dealt  with,  the  patient  shows  symptoms  which 
are  attributable  to  renal  insufficiency. 

Pyo-nephrosis  is  due  to  the  ascending  infection  of  a 
hydro-nephrosis,  and,  in  addition  to  the  signs  and  symp- 
toms already  mentioned,  the  patient  has  high  fever  and 
large  quantities  of  pus  in  the  urine. 

Treatment. — If  there  is  reason  to  believe  that  a  liga- 
ture has  been  placed  round  the  ureter,  an  attempt  should 
be  made  to  remove  it.  If  an  inflammatory  mass  occupies 
the  broad  ligament,  this  must  be  drained  in  the  hope 
that  the  ureteral  condition  will  be  relieved.  Pyo-nephrosis 
must  be  met  by  nephrotomy  and  drainage,  or,  in  the  last 
resort,  nephrectomy. 

Diabetic  Coma 

We  have  on  p.  74  noted  the  appropriate  treatment 
for  diabetes  preparatory  to  operative  treatment. 

After  the  operation  the  urine  should  be  frequently 
examined  for  diacetic  acid,  a  derivative  of  #-oxybutyric 
acid,  and  even  for  the  latter  itself,  since  diabetic  coma  is 
always  preceded  by  the  appearance  of  diacetic  and  /3-oxy- 
butyric  acids  in  the  urine.  A  simple  test  for  diacetic  acid 
is  that  on  adding  to  a  specimen  of  fresh  urine  a  solution  of 
chloride  of  iron  the  mixture  becomes  a  claret  colour.  It 
must  be  remembered  that  formic,  carbolic,  and  salicylic 
acids  in  the  urine  give  the  same  reaction ;  but  whereas 
diacetic  acid  will  not  give  this  reaction  if  the  urine  is  boiled, 


664  GYNAECOLOGICAL  SURGERY 

the  other  acids  will.  In  fermented  urine,  on  polariscopic 
examination,   /3-oxybutyric  acid  is  lsevorotatory. 

We  have  met  with  one  case  of  diabetic  coma,  and  this, 
in  spite  of  all  treatment,  terminated  fatally. 

If  from  the  urine  it  is  evident  that  diabetic  coma  may 
be  imminent,  the  amount  of  bicarbonate  of  soda  given  by 
the  mouth  should  be  increased  up  to  as  much  as  3 
ounces  a  day,  or  until  the  urine  becomes  alkaline. 

If  coma  supervenes,  the  patient  should  be  treated  by 
oxygen-inhalation  and  intravenous  injections  of  a  drachm 
of  bicarbonate  of  soda  in  a  pint  of  normal  saline  solution 
or  sterilized  water  every  few  hours,  if  the  maximum  dose 
of  this  drug  has  not  already  been  reached. 

COMPLICATIONS    AFTER    SALINE   INJECTION 

We  have  seen  one  case  of  thrombosis  of  the  brachial  vein 
follow  intravenous  injection,  and  two  cases  of  submammary 
abscess  after  subcutaneous  injection  under  the  breasts.  In 
all  three  cases  the  usual  steps  had  been  taken  to  render  the 
skin-area  as  aseptic  as  time  would  permit. 

On  the  two  occasions  when  the  submammary  abscesses 
formed  it  was  interesting  to  note  that  the  condition  appeared 
to  cause  no  discomfort  until  a  large  amount  of  pus  had 
accumulated.  The  temperature  was  raised,  but  the  com- 
plete absence  of  most  symptoms  caused  the  condition  to  be 
overlooked  for  some  time. 


CHAPTER    XXXIX 
POSTOPERATIVE    COMPLICATIONS    (Concluded) 

EMBOLISM  AND  THROMBOSIS  OF  THE  SUPERIOR 
MESENTERIC    ARTERIES 

These  are  rare  complications  after  gynaecological  opera- 
tions. The  results  depend  upon  the  size  of  the  vessel 
affected. 

If  a  small  vessel  is  affected,  the  signs  and  symptoms 
will  be  those  of  ulcerative  enteritis  or  colitis  as  set  out 
at  p.  625. 

If  a  large  vessel  is  involved,  the  patient  is  des- 
perately ill,  complaining  of  great  pain  and  tenderness  in 
the  abdomen.  Hgematemesis  and  profuse  loss  of  blood 
per  anum  are  present,  and  there  are  signs  of  intestinal 
obstruction  and  general  peritonitis. 

Treatment. — The  predominant  symptoms  must  be  alle- 
viated, but  the  condition  is  practically  hopeless. 

INSANITY 

The  mental  balance  of  a  woman  may  be  disturbed 
after  operations  on  her  genital  organs,  as  after  operations 
on  other  parts  of  her  body.  This  is  not,  however,  peculiar 
to  females,  for  males  sometimes  become  insane  after  opera- 
tions. In  fact,  any  shock  may  be  responsible  for  this 
condition  in  a  mind  weak  from  inheritance  or  from  some 
prolonged  illness. 

In  the  early  days  of  ovariotomy  and  salpingo-cophorec- 
tomy  it  used  to  be  the  fashion  for  medical  men  who  were 
antagonistic  to  these  operations  to  tell  women  that  if 
they  subjected  themselves  to  such  they  would  in  all 
probability  become   insane  ;    and,  in  fact,  such  statements 

665 


666  GYNAECOLOGICAL  SURGERY 

are  still  occasionally  made  by  well-meaning  but  ill-informed 
persons.  As  we  have  indicated,  it  is  not  because  the 
patient  is  a  woman,  nor  because  certain  of  her  genital 
organs  have  been  removed,  that  her  mental  balance  is 
disturbed.  The  exciting  cause  is  the  shock  of  a  severe 
operation,  comparable,  for  instance,  to  the  shock  of  child- 
birth, acting  on  an  ill-balanced  mind  and  predisposed 
to  by  anxiety  concerning  the  approaching  operation,  and, 
in  cases  where  the  ovaries  have  been  removed,  by  the 
succeeding  menopause.  The  natural  menopause  itself  is 
responsible  for  many  more  cases  of  disturbance  of  mental 
balance  than  any  operation. 

When  insanity  follows  soon  after  an  operation,  it  usually 
takes  the  form  of  acute  mania. 

Treatment.  — ■  These  patients  are  very  difficult  to  treat, 
on  account  of  the  wound.  They  must  be  gently  restrained, 
and  two  nurses  must  be  in  constant  attendance  day  and 
night.  Feeding  is  often  a  matter  of  difficulty,  the  patient 
refusing  nourishment.  She  must  be  persuaded,  if  possible, 
and,  this  failing,  the  nasal  tube  must  be  used.  Various 
drugs  may  be  exhibited,  such  as  sulphonal,  paraldehyde, 
and  the  bromides,  the  first  two  being  the  most  satis- 
factory. Opium  and  morphia,  as  a  rule,  are  contra- 
indicated. 

Hospital  patients  must  be  removed  to  an  asylum  as 
soon  as  is  convenient.  Whether  or  not  private  patients,, 
who  can  afford  to  pay  for  the  services  of  properly-trained 
asylum  nurses,  should  be  sent  to  a  private  asylum,  is  a 
matter  for  careful  consideration.  If  they  are  so  sent,  the 
stigma  of  having  been  in  an  asylum  is  incurred.  On  the 
other  hand,  if  the  patient  is  treated  at  home  she  is  apt 
on  recovery  to  insist  on  leaving  the  place  which  is  associated 
with  such  unpleasant  reminiscences  ;  and  also  it  must  be 
remembered  that  these  patients  take  astonishing  likes  and 
dislikes  to  their  nurses,  so  that  the  latter  may  have  to  be 
frequently  changed,  which  can  only  be  conveniently  done 
in  an  asylum. 


POSTOPERATIVE   COMPLICATIONS        667 

CEREBRAL   THROMBOSIS,    CEREBRAL 
HEMORRHAGE 

These  complications  have  rarely  been  noticed  to  follow 
a  gynaecological  operation.  If  the  condition  arises  during 
the  administration  of  the  anaesthetic,  the  patient  does  not 
recover  consciousness  after  the  termination  of  the  opera- 
tion. On  the  other  hand,  the  disease  may  not  arise  till 
some  little  time  after  the  operation,  in  which  case  the 
patient,  suddenly  or  gradually,  will  become  unconscious. 
The  cerebral  haemorrhage  may  take  place  during  severe 
straining  or  violent  sickness.  The  usual  symptoms  and 
signs  associated  with  the  above  conditions  will  be  present, 
and  need  not  be  further  detailed. 

JAUNDICE 

This  condition  sometimes  occurs  after  abdominal  sec- 
tion, and,  as  a  rule,  it  is  of  serious  prognosis,  since  it  is 
generally  the  result  of  septicaemia  or  pylephlebitis  (p.  619). 

CUTANEOUS    ERUPTIONS 

Various  urticarial  manifestations  may  be  met  with  after 
abdominal  section,  the  commonest  of  which  is  an  enema 
rash.  This  is  scarlatiniform  in  character,  is  irritable,  and 
appears  first  on  the  buttocks  and  the  abdomen.  It  follows 
in  a  few  hours  the  administration  of  a  soap-and-water 
enema.  Diffuse  urticarial  patches  are  sometimes  found 
on  the  abdomen  under  the  dressing,  especially  if  this  is 
medicated. 

As  a  result  of  shaving  the  pubes,  the  hair-follicles  may 
become  inflamed,  giving  rise  to  sycosis,  a  troublesome  con- 
dition which  may  take  a  long  time  to  settle  down.  The 
use  of  strong  mercurial  dressings  at  times  provokes  a 
regular  dermatitis  of  the  abdomen,  as  may  the  use  of  strong 
antiseptics  (especially  iodine)  to  sterilize  the  skin,  while  the 
adhesive  strapping  across  the  abdominal  wound,  especially 
if  it  is   frequently  removed  and  reapplied,   may  provoke 


668  GYNECOLOGICAL  SURGERY 

similar  trouble  (p.  634).  Septic  rashes  when  they  appear 
are  usually  scarlatiniform  in  character,  but  they  may  be 
haemorrhagic.  The  general  state  of  the  patient  will  point 
to  their  nature. 

DRUG-POISONING 

In  the  course  of  gynaecological  surgery  it  may  be  neces- 
sary to  administer  various  drugs,  internally  as  mixtures, 
pills,  douches,  and  injections,  and  externally  in  the  form 
of  fomentations  or  compresses.  If  care  is  not  taken  when 
prescribing  drugs  in  these  circumstances,  too  strong  a 
dose  may  be  ordered,  with  the  result  that  well-marked 
symptoms  arise.  Certain  people,  too,  have  idiosyncrasies 
for  particular  kinds  of  drugs,  and  even  a  small  dose  in 
them  will  produce  symptoms  and  signs  which  may  be 
puzzling  or  even  alarming. 

Mercury.  —  When  applied  to  the  skin  in  the  form  of 
a  compress,  this  drug  may  cause  an  erythematous  rash 
with  the  formation  of  vesicles  which  at  times  develop  into 
pustules.  According  to  Malcolm  Morris,  mercury,  when 
taken  internally,  may  produce  almost  any  kind  of  skin-lesion, 
and  the  effect  of  the  drug  may  simulate  urticaria,  herpes, 
impetigo,  or  furuncle.  Sometimes  it  produces  extensive 
ulceration.  The  condition,  which  may  last  six  months  or 
more,  has  to  be  diagnosed  from  measles  and  the  other 
eczematous  fevers. 

If  the  case  is  one  of  mercurial  poisoning  the  patient 
will  complain  of  a  metallic  taste,  soreness  of  the  gums, 
nausea,  and  perhaps  a  severe  colic,  while  an  examination 
will  show  that  there  is  a  red  line  on  the  gums,  the  teeth 
may  be  loose,  there  is  much  salivation,  the  breath  is  very 
fetid,  diarrhoea  is  present  with  perhaps  melaena,  the  pulse 
is  small  and  rapid,  the  countenance  anxious,  and  the  skin 
cold  and  clammy.  Fatal  cases  of  mercurial  poisoning  have 
occurred  after  an  intra-uterine  douche  of  perchloride  of 
mercury,  1 — 2,000. 

Carbolic    acid.  —  This  substance  will  cause  an  erythe- 


POSTOPERATIVE   COMPLICATIONS        669 

matous  rash,  and  if  the  patient  is  poisoned  she  will  have 
headache,  vomiting,  the  quantity  of  urine  will  be  diminished 
and  it  will  be  dark-green  or  blackish  in  colour. 

Belladonna.  • — ■  The  rash  of  belladonna  or  atropin  re- 
sembles that  of  scarlet  fever.  As  a  rule,  it  affects  the  face, 
neck,  and  trunk,  and  is  accompanied  by  severe  itching  of 
the  skin.  In  addition,  the  patient  may  complain  of  being 
very  thirsty  and  having  a  very  dry  throat  and  mouth.  The 
pupils  will  be  dilated,  and  in  severe  cases  of  poisoning  there 
will  be  delirium. 

Bromides  and  iodides. — A  large  number  of  people  are 
unable  to  take  the  bromides  of  potassium,  ammonium,  or 
sodium  without  a  resulting  skin-eruption,  which  may  be  in 
the  form  of  papules,  vesicles,  or  pustules.  The  rash  is 
acneiform,  and  the  part  affected  is  generally  the  forehead, 
nose,  and  back  of  shoulders.  The  eruptions  due  to  the 
iodides  resemble  more  or  less  those  due  to  bromides.  They 
are,  however,  quicker  in  development  and  more  painful. 

Chloral  hydrate. — Chloral  hydrate  sometimes  causes  a 
diffuse  erythematous  rash  on  the  skin,  especially  the  head 
and  face.  The  rash  is  unattended  with  constitutional 
symptoms,  and  quickly  fades.  The  taking  of  food  and  the 
drinking  of  tea  or  alcohol  has  a  marked  effect  in  increas- 
ing the  severity  of  the  rash. 

Quinine.  —  Quinine  may  cause  skin-lesions  of  various 
types.  Erythema,  papules,  vesicles,  bullae,  pustules,  and 
petechias  may  result.  The  mucous  membrane  of  the  throat 
may  be  affected,  and  consequently  the  condition  may  be 
mistaken  for  scarlet  fever.  As  a  rule,  however,  there  is  no 
fever.  The  quinine  can  be  detected  in  the  urine.  Some 
patients,  as  is  well  known,  are  unable  to  take  quinine 
owing  to  severe  headache  or  noises  in  the  head  following 
its  administration. 

Opium. — Opium  sometimes  causes  a  scarlatiniform  rash, 
and  sometimes  a  rash  resembling  measles.  The  face  and 
neck  are  the  usual  seats  of  the  eruption,  which  is  generally 
preceded  by  heat  and  severe  itching.     Medicinal  doses  of 


670  GYNECOLOGICAL  SURGERY 

opium  may  give  rise  to  severe  nausea  and  vomiting  in  some 
patients,  and  in  those  who  are  very  susceptible  to  its 
influence  a  small  dose  will  cause  one  or  other  of  the  well- 
known  signs  of  opium-poisoning. 

Strychnine. — It  is  our  custom,  as  has  been  mentioned, 
to  administer  strychnine  twice  a  day  some  few  days  before 
a  serious  operation.  If  this  treatment  is  followed,  a  careful 
watch  must  be  kept  to  make  sure  that  signs  of  strychnine- 
poisoning  are  not  developing,  some  persons  being  much 
more  susceptible  to  the  drug  than  others.  If  the  patient 
commences  to  complain  of  the  neck  and  face  muscles  being 
stiff,  or  if  the  hands  twitch,  and  the  reflexes  are  found 
markedly  increased,  it  is  time  to  discontinue  the  use  of  the 
drug. 

MISCARRIAGE   AFTER   OPERATIONS 

The  liability  to  miscarriage  after  operations  on  the 
genital  organs  varies  markedly  in  different  patients,  and 
also  according  to  the  nature  of  the  operation  that  has  been 
performed.  If  it  has  been  necessary  to  operate  upon  a 
pregnant  woman  and  the  pregnant  uterus  itself  has  not 
been  removed,  we  always  keep  the  patient  under  the  in- 
fluence of  morphia  after  the  operation  for  at  least  forty- 
eight  hours.  The  exact  amount  to  be  given  must  be  judged 
by  circumstances.  The  hypodermic  injection  of  one-third  of 
a  grain  may  be  given  as  soon  as  the  patient  has  recovered 
from  the  anaesthetic,  and  subsequent  doses  of  a  quarter  of 
a  grain  may  be  administered  to  keep  the  pupils  slightly 
contracted,  but  not  oftener  than  every  six  hours.  If  mis- 
carriage does  occur,  it  must  be  treated  on  ordinary  principles. 
In  cases  of  premature  labour,  the  natural  efforts  after  full 
dilatation  of  the  os  must  be  assisted  by  chloroform  and  the 
use  of  forceps. 

BEDSORES 

Bedsores  are  generally  the  result  of  careless  nursing, 
and  should  not  occur  if  the  back  of  the  patient  is  attended 
to  as  described  at  p.  569.     They  are  particularly  liable  to 


POSTOPERATIVE  COMPLICATIONS       67 r 

occur  in  ill-nourished,  debilitated  persons,  or  where  the 
parts  are  kept  constantly  wet  by  the  incontinent  flow 
of  urine  or  faeces.  If  a  bedsore  should  form,  the  conval- 
escence may  be  prolonged  for  many  weeks.  The  severity 
of  the  lesions  varies  from  a  mere  breaking  of  the  skin  to 
deep  sloughing.  They  should  be  treated  by  relieving  the 
pressure  by  means  of  a  ring  cushion  or  a  water-bed,  and 
by  the  application  of  zinc  ointment  spread  on  pieces  of 
lint.  If  there  is  definite  sloughing,  peroxide  of  hydrogen 
should  be  used  until  the  surface  is  healthy.  The  surround- 
ing skin  must  be  kept  scrupulously  clean  and  dry. 

COMPLICATIONS   DUE   TO   THE   ANESTHETIC 

Posture  paralysis. — As  the  result  of  faulty  posture  on 
the  operation-table,  or  ill-adjusted  retention  apparatus, 
certain  muscles  of  the  arms  or  legs  may  become  paralysed. 

Arm. — i.  The  commonest  injury  to  the  arm  is  due  to 
its  having  been  allowed  to  hang  over  the  edge  of  the  table 
during  a  prolonged  operation.  The  musculo-spiral  nerve  is 
thus  damaged,  resulting  in  paralysis  more  or  less  complete 
of  the  muscles  supplied  by  it.  If  the  pressure  is  above  the 
point  where  the  branches  to  the  triceps  are  given  off,  the 
patient  will  be  unable  to  extend  her  forearm,  wrist,  or 
fingers.  If  the  pressure  is  below  this,  the  triceps  escapes 
and  the  muscles  at  the  back  of  the  forearm  are  alone 
affected.  Anaesthesia  is  variable  in  amount,  but  it  may 
occur  along  the  outer  side  and  back  of  the  forearm, 
the  outer  half  of  the  back  of  the  hand,  the  back  of  the 
thumb,  index  and  middle  fingers,  and  the  outer  half  of 
the  ring  finger. 

ii.  The  brachial  plexus  may  be  injured  by  the  shoulder- 
straps  that  are  sometimes  used  to  support  the  patient  in 
the  Trendelenburg  position.  As  a  result,  all  or  some  of 
the  muscles  of  the  shoulder  and  the  upper  extremity  may 
be  paralysed.  The  patient  will  be  unable  to  use  her  arm, 
and  for  weeks  may  be  unable  to  do  her  hair. 

Leg. — i.  The  crutch  used  for  maintaining  the  patient  in 


672  GYNECOLOGICAL  SURGERY 

the  lithotomy  position  is  sometimes  responsible  for  injury 
to  the  peroneal  nerve,  owing  to  the  pressure  of  the  stirrup 
which  holds  the  leg.  This  accident  is  due  to  not  flexing 
the  thigh  sufficiently  so  as  to  prevent  the  weight  of  the 
leg  from  pulling  against  the  stirrup.  It  is  also  likely  to 
occur  if  the  leg  is  not  protected  by  a  stocking.  The  result 
is  foot-drop. 

ii.  The  Trendelenburg  tilt  may  be  the  cause  of  a  similar 
injury  to  the  popliteal  nerve  if  the  popliteal  space  is  com- 
pressed against  the  bottom  edge  of  the  operating-table. 
This  accident  is  due  to  the  leg  being  insufficiently  flexed 
on  the  thigh,  an  accident  which  may  occur  either  from 
the  patient  being  too  far  up  the  table  at  the  time  the  legs 
are  first  strapped  to  the  foot-pieces,  or  because,  although 
she  is  correctly  strapped  (i.e.  with  the  leg  at  right  angles 
to  the  thigh),  the  foot-pieces,  being  hinged,  have  from  lack 
of  proper  clamping  subsequently  extended. 

Crushes  and  dislocations. — Unless  great  care  be  taken 
when  the  patient  is  being  lowered  from  the  tilted  to  the 
horizontal  position,  the  hands  or  arms  may  be  caught 
between  the  top  of  the  table  and  the  frame,  resulting  in 
severe  bruising,  fracture,  laceration,  or  injury  to  the  nerves. 
The  shoulder  may  be  easily  dislocated  when  the  patient  is 
under  the  influence  of  an  anaesthetic  unless  care  be  taken, 
when  moving  the  arms,  to  avoid  over-extension  of  the 
shoulder-joint.  The  accident  is  most  likely  to  occur  when 
the  nightgown,  having  become  soiled,  is  being  changed  while 
the  patient  is  on  the  table  before,  being  put  back  to  bed. 

Conjunctivitis.  —  It  occasionally  happens  that  the 
surgeon,  on  visiting  his  patient  the  day  following  the  opera- 
tion, finds  the  eyelids  red  and  swollen.  On  examination, 
conjunctivitis  is  discovered,  which  is  usually  due  either  to 
a  drop  of  the  anaesthetic  having  been  allowed  to  fall  into 
the  eye,  or  to  the  bad  habit  some  anaesthetists  have  of 
continually  touching  the  eyeball  to  ascertain  the  condition 
of  the  patient's  reflexes.  Conjunctivitis,  though  very  pain- 
ful   and    annoying,  always   clears  up    in    a    few    days.     It 


POSTOPERATIVE  COMPLICATIONS        673 

should  be  treated  by  irrigation  with  boric-acid  solution, 
cold  pads  to  the  eye,  and  boric  ointment  between  the  lids 
to  prevent  them  sticking. 

Burns,  i.  Anaesthetic  burns. — If  the  cheeks,  lips,  and 
nose  are  not  covered  with  a  thin  layer  of  grease  before 
chloroform  is  administered,  they  may  be  burnt  by  the  drug 
coming  in  contact  with  the  skin,  and  an  annoying  dermatitis 
results,  disfiguring  the  patient  for  a  few  days. 

This  condition  is  best  treated  by  boric-acid  ointment. 

ii.  Hot-water  bottles. — As  we  have  already  pointed  out, 
hot-water  bottles  must  be  used  with  the  greatest  care, 
for  a  bad  hot-water  bottle  burn  is  a  disaster  of  the  first 
magnitude,  entailing  expense  and  physical  suffering  to  the 
patient,  mental  distress  to  the  surgeon,  and  liability  to  legal 
proceedings  against  the  nurse. 

The  worst  burns  have  been  those  caused  on  the  table, 
due  (1)  to  the  hot-water  bottle  which  was  placed  on  the 
table  to  warm  it  having  been  forgotten  when  the  patient 
was  placed  in  position  ;  (2)  to  unprotected  bottles  having 
been  placed  against  the  patient's  side  throughout  the  opera- 
tion, or  on  the  chest  in  cases  of  sudden  heart-failure  ;  or 
(3)  to  contact  of  the  patient  with  the  unguarded  metal  of 
an  operating-table  intentionally  heated  by  hot  water.  Very 
serious  burns  may  also  result  from  placing  unprotected  hot 
bottles  against  the  patient  in  bed  while  she  is  recovering 
from  the  anaesthetic. 

There  is  nothing  which  it  behoves  the  surgeon  to  be 
more  careful  to  oversee  than  the  use  of  hot-water  bottles. 
With  modern  highly-trained  nurses  these  burns  are  most 
likely  to  occur  as  the  result  of  over-zeal  in  an  emergency, 
when,  in  the  immediate  necessity  for  reviving  a  collapsed 
patient,  the  danger  of  using  unprotected  bottles  is  forgotten. 
We  think  that  hot-water  bottles  should  never  be  placed 
on  the  operating-table,  nor  do  we  see  any  advantage  in 
the  use  of  tables  that  are  artificially  warmed.  A  properly 
heated  room  is  the  best  method  of  avoiding  shock  in  this 
connexion.      The  proper  way  to  apply  hot-water    bottles 

2R 


674  GYN/ECOLOGICAL  SURGERY 

after  the  patient  has  been  returned  to  bed  is  described 
at  p.  548. 

The  burn  caused  by  a  hot-water  bottle  is  peculiarly 
destructive,  owing  to  the  length  of  time  the  heat  acts  and 
the  depth  to  which  the  tissues  are  consequently  involved. 
When  first  examined,  nothing  but  an  area  varying  in  tint 
from  a  bright  pink  to  a  rusty  purple  is  seen.  Later  on, 
vesicles  appear,  and  in  bad  cases  the  whole  of  the  affected 
area  for  a  thickness  of  an  inch  or  more  may  slough  out  and 
an  extensive  disfiguring  scar  result. 

Treatment.  —  When  the  burn  is  discovered,  it  should 
be  at  once  covered  with  lint  spread  with  boric-acid  ointment. 
If  vesication  takes  place  the  blister  may  be  pricked.  In 
the  event  of  sloughing,  the  boric-ointment  lint  should 
be  exchanged  for  repeated  warm  boric-acid  fomentations 
until  the  surface  has  become  clean,  when,  if  small, 
it  may  be  allowed  to  granulate  up,  with  the  aid  of 
red  lotion  if  necessary,  but  if  large  it  should  be  skin- 
grafted. 

Injuries  to  teeth  and  gums.  —  When,  during  the  ad- 
ministration of  the  anaesthetic,  it  is  necessary,  on  account 
of  the  patient's  tongue  falling  back  and  interfering  with 
respiration,  to  open  the  mouth  with  a  gag  and  pull  the 
tongue  forwards  with  forceps,  the  gag  has  been  known  to 
force  out  a  tooth  or  lacerate  the  gums,  and  if  the  forceps 
is  used  for  any  length  of  time  the  tongue  is  always  bruised 
and  excoriated.  As  a  rule,  these  accidents  can  be  prevented 
by  gentleness  in  manipulation.  The  soreness  which  the 
patient  has  to  endure  for  some  days  must  be  treated  with 
antiseptic  month-washes. 

Chloroform  introduced  into  the  stomach.  —  This  acci- 
dent can  only  happen  with  a  Junker's  apparatus  that  has 
been  wrongly  put  together — i.e.  when  the  bulb-tube  occu- 
pies the  position  of  the  delivery-tube,  the  result  being  that, 
instead  of  chloroform  vapour,  the  drug  itself  is  pumped 
into  the  patient's  throat.  If  this  accident  occurs  the 
patient  will  probably  die. 


POSTOPERATIVE  COMPLICATIONS        675 

Circulatory  failure. — According  to  Hewitt,*  this  com- 
plication is  predisposed  to  by  (1)  any  impairment  of  general 
health,  such  as  that  dependent  on  anaemia,  jaundice,  renal 
disease,  shock  from  injury  or  loss  of  blood,  and  particularly 
any  grave  respiratory  or  cardiac  affection  ;  (2)  profound 
mental  disturbance  ;  (3)  the  presence  of  food  or  fluid  within 
the  stomach.  It  is  excited  by  (1)  embarrassed  or  arrested 
breathing  ;  (2)  the  toxic  effects  of  the  anaesthetic  itself  upon 
the  cardio-vascular  system  ;  (3)  the  surgical  procedure  ; 
(4)  vomiting. 

The  condition  should  be  treated  by  lowering  the  patient's 
head  and  by  the  maintenance  of  artificial  respiration. 
Injections  of  strychnine  may  be  given  and  ammonia  held 
to  the  nose.  The  heart  may  be  directly  massaged  through 
the  abdominal  opening  if  the  operation  is  an  abdominal 
one,  and  if  it  is  vaginal  the  abdomen  may  be  opened  for 
the  purpose.  Cases  are  on  record  in  which  the  cardiac 
contraction  was  restarted  by  this  means. 

If  the  circulatory  failure  is  due  to  shock  from  haemor- 
rhage, the  head  should  be  lowered,  brandy  enemata  given, 
and  saline  infusion  performed. 

Respiratory  failure.  —  Respiratory  failure  is  due  to 
obstruction,  paralysis,  or  reflex  inhibition.  Obstruction  is 
caused  by  the  tongue  falling  back  or  by  muscular  spasm, 
or  by  foreign  substances  being  sucked  into  the  upper  air- 
passages.  Paralysis  is  due  to  an  overdose  of  the  anaesthetic. 
Reflex  inhibition,  causing  stoppage  of  respiration,  is  spe 
cially  liable  to  occur  where  much  traction  is  being  made 
on  the  abdominal  contents,  as,  for  instance,  during  the 
enucleation  of  a  cervical  myoma.  It  may  also  be  caused 
/by  the  sudden  change  of  posture  occasioned  by  the  assump- 
tion of  the  Trendelenburg  position  or  the  packing  off  the 
intestines  with  the  big  swab. 

Obstruction  is  treated  by  removal  of  the  cause.  If 
paralysis  threatens,  the  complexion  becoming  cyanotic,  the 
pulse  small  and  irregular,  and  the  pupil  reflex  insensitive, 

*  "  Anaesthetics  and  their  Administration." 


676  GYNECOLOGICAL  SURGERY 

the  administration  should  at  once  be  stopped,  the  lips 
rubbed  with  a  towel,  and  expiration  assisted  by  pressure 
on  the  chest.  If  this  fails,  no  time  should  be  lost  in  applying 
artificial  respiration  and  administering  strychnine  hypo- 
dermically.     Oxygen,  if  available,  should  be  administered. 

Reflex  inhibition  is  similarly  treated.  The  surgeon  when 
performing  manoeuvres  involving  much  traction  on  the 
abdominal  contents  will  be  well  advised  to  ask  the  anaes- 
thetist how  the  patient  is  bearing  it,  and,  in  the  event  of 
an  unfavourable  answer,  to  desist  from  his  efforts  until  the 
breathing  is  again  satisfactory,  or  to  get  over  the  operative 
difficulty  in  some  other  way. 

Late  anaesthetic  poisoning.— We  have  seen  one  case  in 
which  death  was  attributed  to  this  cause.  The  symptoms 
were  those  of  peculiar  mental  lethargy,  broken  by  fits  of 
excitement.  Vomiting  was  persistent,  and  the  pulse-rate 
progressively  rose. 

Continuous  saline  infusion  would  appear  to  hold  out 
some  chance  of  success  in  this  rare  condition. 


CHAPTER    XL 

IMMEDIATE   RESULTS   OF   OPERATIONS   ON 
THE  FEMALE  GENITAL  ORGANS 

For  the  proper  appreciation  of  the  value  of  any  statistics 
relating  to  a  particular  operation,  one  must  be  careful  to 
take  into  consideration  the  class  of  patient  dealt  with  and 
the  conditions  under  which  the  operation  was  performed. 
Authors  when  discussing  their  personal  experience  of  an 
operation  are  very  apt  to  base  their  final  judgment  on  its 
relative  value  from  a  consideration  of  the  results  to  all 
the  patients  upon  whom  they  have  performed  it,  quite 
irrespectively  of  whether  it  was  performed  in  a  hospital 
or  in  private.  Whilst  it  is  true  that  in  a  well-appointed 
hospital  theatre,  with  highly  trained  assistants,  an  opera- 
tion is  performed  in  circumstances  the  best  calculated  to 
bring  it  to  a  successful  conclusion,  nevertheless  this  advan- 
tage is  more  than  counterbalanced  by  the  fact  that  a  large 
proportion  of  the  patients  of  a  hospital  are  in  a  miser- 
ably ill-nourished  and  debilitated  state  as  regards  their 
general  condition  and  of  neglect  as  regards  the  disease  for 
which  they  are  admitted.  The  physique  of  private  patients 
is,  on  the  whole,  markedly  superior,  and  because  they  can 
command  efficient  medical  advice  they  present  themselves 
to  the  surgeon  while  the  disease  is  in  a  much  earlier  stage. 
We  have  commented  elsewhere  upon  the  importance  of 
recognizing  this  difference  in  the  class  of  patient  operated 
upon,  and  need  not  further  discuss  it. 

In  this  chapter  we  propose  to  deal  with  the  immediate 
results  of  gynaecological  operations  and  have  taken  for 
this  purpose  all  that  have  been  performed  during  the  six- 
teen years  from  January,  1895,  to  August,  1910,  inclusive, 

677 


678  GYNECOLOGICAL  SURGERY 

at  the  Chelsea  Hospital  for  Women,  and  all  those  of  a 
similar  nature  performed  during  the  same  period  at  the 
Middlesex  Hospital  by  ourselves  and  our  colleagues  there 
who  are  also  on  the  staff  of  the  Chelsea  Hospital.  In  these 
statistics  we  have  not  included  any  cases  operated  upon 
privately,  in  order  that  the  results,  as  already  pointed  out, 
may  convey  a  proper  impression  of  the  relative  danger  of 
operations  performed  upon  a  similar  class  of  patient  by 
the  same  operators  under  similar  conditions  for  sixteen 
years.  One  point  that  should  perhaps  be  mentioned  is  that 
the  patients  treated  at  the  Middlesex  Hospital  are  some- 
what lower  in  the  social  scale,  not  so  well  nourished,  and 
more  often  the  seat  of  some  general  disease,  than  those 
treated  at  the  Chelsea  Hospital  for  Women,  which  was 
founded  for  the  relief  of  poor  gentlewomen.  The  Middlesex 
statistics,  as  a  consequence,  if  taken  by  themselves,  show 
a  higher  mortality  and  those  of  Chelsea  a  lower  mortality 
than  the  combined  mortality  here  given.  Nevertheless,  we 
have  thought  it  right  to  include  both  hospitals  since  the 
work  at  Chelsea  Hospital  is  by  no  means  limited  to  the 
class  for  which  it  was  founded. 

These  statistics  are,  we  hope,  made  more  interesting 
and  useful  by  setting  out,  in  fatal  cases,  the  cause  of  death 
where  it  was  verified  by  post-mortem  examination. 

In  the  following  classification  of  the  causes  of  death, 
"  shock  "  has  been  taken  to  signify  cases  in  which  death 
took  place  from  a  few  hours  to  three  days  or  so  after  the 
operation,  and  in  which  the  post-mortem  examination  dis- 
closed no  definite  cause  of  death.  In  reports,  such  cases  are 
often  entered  up  as  cardiac  failure,  cardiac  dilatation, 
syncope,  and  so  forth.  We  have  also  included  under 
"  shock  "  those  cases  in  which  the  patient  was  practically 
dying  before  admission,  and  an  operation  was  only  per- 
formed as  a  last  desperate  resource. 

It  must  be  -particularly  remembered  when  examining  the 
statistics  that  they  represent  the  work  of  eleven  operators,  cover- 
ing a  period  of  nearly  sixteen  years.     During  that  time  the 


RESULTS-IMMEDIATE 


679 


surgery  of  the  female  genital  organs  has  undergone  a  vast 
change,  and  while  in  many  respects  the  net  results  of  the 
whole  sixteen  years  are  very  gratifying,  the  mortality  from 
year  to  year  during  the  period  under  discussion  shows,  as 
in  all  other  institutions,  a  gradual  improvement,  in  spite 
of  the  fact  that  much  more  formidable  cases  are  now  dealt 
with  than  formerly ;  and  taking  the  last  five  years  the 
mortality  is  considerably  lower  than  in  the  first  ten,  whilst 
in  statistics  more  recent  than  these  the  mortality  is  still 
less.  To  illustrate  this  improvement  we  have  added  tables 
of  the  gynaecological  operations  performed  at  the  Chelsea 
Hospital  from  January,  1905,  to  August,  1910,  inclusive. 

We  would  point  out  further  that  some  of  our  colleagues 
have  had  a  series  of  over  a  hundred  consecutive  abdominal 
sections  without  a  death,  but  it  is  our  object  to  show  what 
results  may  reasonably  be  expected  from  the  work  of 
various  operators,  operating  under  similar  conditions,  but 
with  slight  modifications  of  technique  peculiar  to  them- 
selves. An  average  mortality-rate  cannot,  of  course,  be 
rigidly  applied  to  individual  cases,  each  of  which,  in  view  of 
its  peculiar  conditions  and  circumstances,  is  "  a  law  unto 
itself." 

MAJOR  OPERATIONS 

TOTAL   ABDOMINAL   HYSTERECTOMY 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 

January,  1895 — August,  1910,  inclusive 


Disease 


Cases        Deaths 


Uncomplicated  myomata         .... 
Myomata  complicated  with  other  pelvic  disease 
Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Bilateral  salpingitis         .... 
Procidentia  uteri  ..... 
Puerperal  sepsis     ..... 
Carcinoma  and  sarcoma  of  the  corpus  uteri 
Carcinoma  of  the  cervix  uteri 


51 
33 
8 
6 
1 
1 

45 
9 

154 


5 
1 
o 
o 
o 
I 

5 
1 

13 


68o 


GYNAECOLOGICAL  SURGERY 


Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 

I 
Cases       Deaths 

Uncomplicated  myomata         .... 
Myomata  complicated  with  other  pelvic  disease 
Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Bilateral  salpingitis         ..... 
Carcinoma  and  sarcoma  of  the  corpus  uteri    . 
Carcinoma  of  the  cervix  uteri 

12                 1 

27                 1 

3                ° 
1                 0 

18                 1 
6                 1 

67                 4 

CAUSES    OF    DEATH 

Intestinal  obstruction  by  an  old  band 

Postoperative  haemorrhage 

Pulmonary  embolism 

Organic  heart-disease 

Shock 

Preoperative  sepsis 

Peritonitis 

No  post-mortem     . 


13 


Remarks. — The  other  pelvic  conditions  with  which  the 
myomata  were  complicated  were  diseased  appendages, 
ovarian  cysts,  and  pregnancy.  The  cause  of  death  in  two 
of  the  cases  in  which  no  post-mortem  examination  was 
held  was  thought  to  be  "  shock  "  ;  in  the  third,  though  no 
symptoms  or  signs  other  than  heart-failure  were  noted,  it 
was  probably  due  to  septic  intoxication,  the  case  being  com- 
plicated by  a  perimetric  abscess.  In  the  case  of  puerperal 
sepsis  the  uterus  was  riddled  with  abscesses.  It  has  not 
been  the  practice,  either  at  the  Middlesex  Hospital  or 
the  Chelsea  Hospital  for  Women,  to  perform  total  abdo- 
minal hysterectomy  for  myomata  except  in  special  circum- 
stances. This  fact  accounts  for  the  small  number  of  cases 
and  the  relatively  high  percentage-mortality. 


RESULTS-IMMEDIATE 


681 


SUBTOTAL  ABDOMINAL  HYSTERECTOMY 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 

Cases 

Deaths 

Uncomplicated  myomata         .... 

Myomata  complicated  by  other  pelvic  disease    . 
Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Salpingitis     ....... 

Carcinoma  of  the  corpus  uteri 

Uterine  prolapse    ...... 

873 

360 

60 

43 

3 

4 

47 
15 
1 
0 
0 
2 

i,343 

65 

Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 

Cases 

Deaths 

Uncomplicated  myomata         .... 

Myomata  complicated  by  other  pelvic  disease    . 
Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Salpingitis     ....... 

Carcinoma  of  the  corpus  uteri 

Uterine  prolapse    ...... 

1 97 

186 

37 

3* 

1 

4 

3 
3 
1 
0 
0 
2 

456 

9 

causes  of  death 

Peritonitis 

Pulmonary  embolism 

Postoperative  haemorrhage 

Intestinal  obstruction 

Organic  heart-disease 

Shock 

Broncho-pneumonia 

Preoperative  sepsis 

Hyperpyrexia     . 

Syncope 

Delirium  tremens 

Thrombosis  of  inferior  vena  cava 

Psoas  abscess 

Acute  delirious  mania 

No  post-mortem 


4 
7 
8 
12 
1 
1 
1 
1 
1 
2 
1 
1 
7 


65 


682 


GYNAECOLOGICAL  SURGERY 


Remarks.  —  The  pelvic  complications  of  the  myomata 
included  diseased  appendages,  simple  and  malignant  ova- 
rian tumour,  broad-ligament  cysts,  extra-uterine  gestation, 
uterus  bicornis,  and  diseased  appendix.  Among  the  cases 
of  intestinal  obstruction  was  one  in  which  the  patient  died 
of  broncho-pneumonia  after  a  second  operation  had  success- 
fully relieved  the  obstruction.  In  another  case  the  obstruc- 
tion was  due  to  the  intestine  becoming  adherent  to  some  blood 
which,  on  account  of  a  suboccluding  ligature,  had  oozed 
from  the  stump  and  clotted.  There  were  two  cases  of  that 
very  rare  condition,  thrombosis  of  the  inferior  vena  cava,  in 
one  of  which  the  patient  died  nine  weeks  after  the  operation. 

The  case  of  syncope  occurred  in  a  patient  who  was  just 
ready  to  leave  the  hospital.  The  patient  next  to  her  in 
the  ward  suddenly  became  delirious  and  frightened  her. 
She  died  almost  immediately  afterwards.  There  was  no 
evidence  of  pulmonary  embolism.  In  the  cases  in  which 
no  post-mortem  examination  was  made,  one  patient  died 
apparently  of  heart-failure  eighteen  days  after  the  opera- 
tion ;  one  was  most  seriously  ill  before  admission,  and  her 
death  was  attributed  to  cachexia  ;  two  patients  died  with 
the  symptoms  of  peritonitis  ;  for  the  remaining  deaths  no 
adequate  cause  could  be  assigned. 

VAGINAL   HYSTERECTOMY 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 


Deaths 


Carcinoma  of  the  corpus  uteri 
Carcinoma  of  the  cervix  uteri 
Uterine  prolapse    ...... 

Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Myomata       ....... 

Pyometra      ....... 

Uterus  bicornis      ...... 

Chorion-epithelioma         ..... 


RESULTS-IMMEDIATE 


683 


Chelsea  Hospital  for  Women,  January,  1905— August, 
i9io,  inclusive 


Disease 


Cases 


Deaths 


Carcinoma  of  the  corpus  uteri 
Carcinoma  of  the  cervix  uteri 
Uterine  prolapse    ...... 

Intractable  haemorrhage  (fibrosis,  adeno-myoma) 
Pyometra      ....... 

Uterus  bicornis      .  .  • 

Chorion-epithelioma        ..... 


4 

0 

9 

0 

5 

0 

2 

1 

2 

0 

1 

0 

1 

1 

24 


CAUSES    OF    DEATH 


Peritonitis 
Shock 

Secondary  growths 
Iodoform  poisoning 
No  post-mortem 


Remarks. — In   the  case   in  which  no   post-mortem  was 
held  the  patient  died  with  the  symptoms  of  peritonitis. 


RADICAL   OPERATION   FOR   CARCINOMA   OF   THE 
CERVIX   UTERI 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Operation                                         1     Cases 

Deaths 

Abdominal  hystero- vaginectomy  (Wertheim)    . 
Vaginal  hystero-vaginectomy  (Schauta)   . 

74 

2 

15 

0 

76 

15 

684 


GYNECOLOGICAL  SURGERY 


Chelsea  Hospital  for  Women,  January,  1905 — 

August,  1910,  inclusive 


Operation 

Cases 

Deaths 

Abdominal  hystero- vaginectomy  (Wertheim)     . 

32 

4 

32 

4 

CAUSES   OF   DEATH 

Fatty  degeneration  of  heart,  liver,  pancreas 

(shock) 
Atheroma  of  the  aorta  (shock) 
Peritonitis,  empyema 
Postoperative  haemorrhage  . 
Intestinal  obstruction 
Pulmonary  embolism,  thrombosis  of  common 

iliac  vein 
Paretic  obstruction 
Shock         .... 
No  post-mortem 


1 
1 
1 
1 

1 

1 
1 
1 
7 

15 


Remarks. — Of  the  cases  in  which  no  post  -  mortem 
examination  was  held,  one  died  of  double  pneumonia ;  one 
of  intestinal  obstruction  (due  to  bands  of  adhesion)  which 
was  relieved  by  a  second  operation,  but  the  operation 
failed  to  save  the  patient ;  one  of  bronchitis  and  cardiac 
failure  ;  one  apparently  of  toxaemia,  the  wound  sloughing ; 
the  remaining  three  apparently  of  shock. 

This  operation  has  only  been  performed  since  1907. 
Most  of  these  patients,  when  they  are  operated  upon,  are 
in  a  very  unhealthy  and  debilitated  condition  from  the  dis- 
charge and  haemorrhage,  and  it  is  not  surprising  therefore 
that  the  majority  of  the  deaths  are  due  to  "  shock."  The 
intestinal  obstruction  was  due  to  a  part  of  the  fascial 
layer  opening  up  some  days  after  the  operation,  when  the 
patient  was  recovering  satisfactorily,  and  a  piece  of  intes- 
tine slipping  between  the  fascial  edges  and  being  partially 
nipped.     The   indifferent   healing   properties   of   the    abdo- 


RESULTS-IMMEDIATE 


685 


minal  wound  in  these  cases  have  been  noted  in  an  earlier 
chapter. 

ABDOMINAL  MYOMECTOMY 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 

Cases 

Deaths 

Uncomplicated  myomata         .... 
Myomata  complicated  by  other  pelvic  disease 

79 
3i 

2 
4 

no 

6 

Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 

Cases 

Deaths 

Uncomplicated  myomata        .... 
Myomata  complicated  by  other  pelvic  disease 

22 
14 

0 

2 

36 

2 

CAUSES    OF    DEATH 

Postoperative  haemorrhage 

Intestinal  obstruction 

Shock  .... 

Anaesthetic  poisoning 

Fatty  degeneration  of  the  heart 

No  post-mortem 


Remarks. — The  complications  associated  with  myomec- 
tomy consisted  of  pregnancy,  diseased  appendages,  ovarian 
tumours,  retroversion,  and  prolapse. 

The  intestinal  obstruction  was  due  to  blood-clot,  and 
was  relieved  by  a  second  operation,  but  the  patient  died 
subsequently  of  pulmonary  disease.  The  cause  of  death 
in  the  case  where  -there  was  no  post-mortem  examination 
could  only  be  diagnosed  as  shock. 


686 


GYNECOLOGICAL  SURGERY 


OVARIOTOMY    (INCLUDING   BROAD-LIGAMENT 
CYSTS  AND  SOLID  TUMOURS  OF  THE  OVARY) 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 


Uncomplicated  unilateral  innocent  cysts  and 
tumours  ...... 

Uncomplicated  bilateral  innocent  cysts  and 
tumours  ...... 

Innocent  cysts  and  tumours  complicated  by 
other  pelvic  disease  .... 

Malignant  ovarian  cysts  and  tumours 


Cases 

Deaths 

7i3 

23 

145 

9 

53 

0 

57 

14 

46 


Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 

Cases       Deaths 

Uncomplicated  unilateral  innocent  cysts  and 
tumours            ...... 

Uncomplicated  bilateral  innocent  cysts  and 
tumours           ...... 

Innocent  cysts  and  tumours  complicated  by 
other  pelvic  disease           .... 

Malignant  ovarian  cysts  and  tumours 

187 
34 

23 
13 

5 
1 

1 
1 

257 

8 

CAUSES   OF 

DEATH 

Peritonitis            .           .           .           .           .                 15 

Intestinal  obstruction 

8 

Pulmonary  embolism 

1 

Shock 

5 

Postoperative  haemorrhage 

3 

Perforated  gastric  ulcer 

1 

Cerebral  embolism       .        ,  . 

1 

Organic  heart-disease 

3 

Cerebral  haemorrhage 

1 

Carcinoma  of  pylorus 

1 

Bronchitis 

1 

Diabetic  coma    . 

• 

1 

No  post-mortem 

5 

46 


RESULTS-IMMEDIATE 


687 


Remarks.  —  The  other  conditions  which  complicated 
this  operation  were  pregnancy,  diseased  appendages,  and 
resection  of  intestine.  It  is  interesting  to  note — and  this  has 
been  pointed  out  by  other  observers — the  high  mortality 
associated  with  malignant  ovarian  disease. 

Two  cases  of  intestinal  obstruction  were  preoperative 
in  nature  and  the  patients  were  practically  dying  when 
admitted.  Another  death  was  due  to  a  secondary  growth 
in  the  rectum  overlooked  at  the  primary  operation,  and  in 
a  fourth  case  the  obstruction  was  found  to  be  multiple 
and  due  to  old  peritonitic  adhesions  from  preoperative 
inflammation  of  the  tumour.  Of  the  cases  in  which  no  post- 
mortem examination  was  held,  one  patient  died  with  the 
signs  of  pneumonia,  another  had  general  suppurative  peri- 
tonitis and  subphrenic  abscess  at  the  time  of  the  operation, 
and  the  others  died  with  the  symptoms  of  shock. 

Comparing  the  results  of  ovariotomy  with  those  of  abdo- 
minal hysterectomy,  it  is  interesting  to  note  that  over  the 
sixteen  years'  period  the  mortality  is  much  the  same  (about 
5  per  cent.),  whilst  in  the  last  five  years  the  death-rate  of 
the  latter  operation  has  fallen  much  below  that  of  the 
former. 


SALPINGO-OOPHORECTOMY  AND  SALPINGECTOMY 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 

Cases 

Deaths 

Unilateral  salpingitis  ..... 
Unilateral  salpingitis  complicated  by  other  pelvic 

disease    ....... 

Bilateral  salpingitis         ..... 

Bilateral  salpingitis  complicated  by  other  pelvic 

disease    ....... 

Myomata       ....... 

Carcinoma  of  Fallopian  tube 

377 

37 
333 

21 
1 

11 

1 
21 

0 

1 
0 

783 

34 

688  GYNECOLOGICAL  SURGERY 

Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 

Cases 

Deaths 

Unilateral  salpingitis  ..... 
Unilateral  salpingitis  complicated  by  other  pelvic 

disease        ....... 

Bilateral  salpingitis         ..... 

Bilateral  salpingitis  complicated  by  other  pelvic 

disease        ....... 

112 

47 
147 

12 

2 

1 

1 

0 

318 

4 

CAUSES    OF    DEATH 


Peritonitis            ..... 

21 

Intestinal  obstruction 

2 

Shock         ...... 

4 

Postoperative  haemorrhage 

1 

Gangrene  of  bowel     .... 

2 

No  post-mortem          .... 

4 

34 


Remarks. — The  complicating  conditions  were  disease  of 
the  appendix  and  necrotic  lymphatic  glands. 

Among  the  cases  of  peritonitis  was  one  in  which  acute 
peritonitis  was  present  before  the  patient  entered  the 
hospital.  In  one  case  in  which  there  was  no  post-mortem 
examination  the  patient  died  with  the  symptoms  of  peri- 
tonitis, in  two  the  symptoms  of  shock  were  present,  and 
in  the  remaining  one  the  patient  died  of  peritonitis  seventeen 
hours  after  the  first  operation,  the  abdomen  being  reopened 
and  several  pints  of  fluid  evacuated.  The  intestine  was 
probably  injured,  but  there  was  no  sign  of  this  at  either 
operation. 

The  frequency  with  which,  in  the  above  table,  peritonitis 
is  the  cause  of  death  will  be  noticed.  This  is  due,  of 
course,  to  the  fact  that  a  large  number  of  these  cases 
are  infectedjbbefore  the  operation. 


RESULTS-IMMEDIATE 


689 


INTRAPERITONEAL    SHORTENING    OF    THE 
ROUND    LIGAMENTS 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 

Cases    \   Deaths 

Retroversion            ...... 

64                 0 

64                 0 

Remarks.  —  This  operation,  which  we  have  performed 
during  the  last  two  years,  has  given  us  satisfaction.  We 
have  used  the  Noble-Barrett  method  as  described  on  p.  443. 
Twenty-seven  of  these  sixty-four  cases  were  operated  upon 
at  the  Chelsea  Hospital. 

VENTRO-SUSPENSION 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 

Cases 

Deaths 

Uncomplicated  retroversion  or  prolapse  . 
Retroversion  or  prolapse  complicated  by  other 
pelvic  disease      ...... 

5io 

197 

1 

2 

707 

3 

Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease                                             Cases 

Deaths 

Uncomplicated  retroversion  or  prolapse  . 
Retroversion  or  prolapse  complicated  by  other 
pelvic  disease     ...... 

239 
139 

0 

1 

378 

1 

2  S 


690 


GYNECOLOGICAL  SURGERY 


CAUSES    OF    DEATH 


Broncho-pneumonia  . 
Pulmonary  embolism 
No  post-mortem 


Remarks. — The  other  conditions  complicating  the  uterine 
displacement  have  been  diseased  appendages,  ruptured 
perineum,  ovarian  prolapse,  diseased  appendix,  movable 
kidney,  endometritis,  and  myomata. 

The  patient  on  whom  no  post-mortem  examination  was 
held  died  of  diabetic  coma.  She  had  no  symptoms  of 
diabetes,  and  the  disease  was  only  discovered  after  the 
operation.  The  patient  progressed  apparently  well  for  a 
week,  and  then  the  abdominal  wound  sloughed,  as  did 
also  the  wound  resulting  from  a  colpo-perineoplasty,  and 
on  the  twelfth  day  she  suddenly  became  comatose  and 
died. 


EXTRA-UTERINE    GESTATION 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Disease 


Cases       Deaths 


Tubal  gestation     ...... 

Tubal  gestation  complicated  with  other  disease 


223 

2 


Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Disease 


Cases       Deaths 


Tubal  gestation     ......  65  3 

Tubal  gestation  complicated  with  other  disease  2  1 


67 


RESULTS-IMMEDIATE 

CAUSES    OF    DEATH 

Peritonitis            ..... 

i 

Pulmonary  embolism 

i 

Intestinal  obstruction 

I 

Shock         ...... 

2 

Septicaemia          ..... 

I 

No  post-mortem           .... 

2 

691 


Remarks. — The  patient  who  died  from  sepsis  was  suffer- 
ing from  septicaemia  on  admission  ;  in  the  two  cases  of 
"  shock  "  the  patients  were  nearly  dead  from  preopera- 
tive haemorrhage  before  admission ;  one  patient  upon 
whom  no  post-mortem  examination  was  held  was  suffering 
on  admission  from  acute  Bright's  disease  and  died  of 
heart -failure,  and  the  other  died  of  intestinal  obstruction. 

In  this  last  case  the  gestation  was  of  four  months' 
duration  and  was  further  complicated  by  an  inflamed 
myoma  the  size  of  a  grape-fruit,  for  which  subtotal  hyster- 
ectomy had  to  be  performed.  The  operation  had  to  be 
completed  quickly,  as  towards  the  end  the  patient's  con- 
dition became  alarming.  There  was  no  time  to  suture 
the  peritoneum  over  the  stump  of  the  cervix,  and  some 
days  later  intestinal  obstruction  slowly  supervened  from 
the  gut  becoming  adherent  to  the  stump  ;  and  although  this 
was  relieved  by  a  second  operation,  the  patient  died. 

CESAREAN    SECTION 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 

January,  1895 — August,  1910,  inclusive 


Nature  of  operation 

Cases 

Deaths 

Conservative,  for  contracted  pelvis 

Caesarean  hysterectomy  for  contracted  pelvis    . 

For  dermoid  of  the  ovary      .... 

For  congenital  malformation  of  the  cervix 

For  carcinoma  of  the  rectum 

For  malignant  peritonitis        .... 

10 
6 
1 

1 
1 
1 

1 

0 
0 
0 
0 
0 

20 

1 

6g2 


GYNECOLOGICAL  SURGERY 


Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Nature  of  operation 

Cases       Deaths 

Conservative,   for  contracted  pelvis 
For  congenital  atresia  of  cervix 
For  malignant  peritoneal  growth     . 

6                 0 
1                  0 
1                  0 

8 

0 

Remarks. — In  the  one  fatal  case  the  cause  of  death 
was  shock.  The  patient,  who  was  very  stout,  was  admitted 
into  hospital  on  the  third  day  of  obstructed  labour.  She 
was  at  that  time  in  a  desperate  condition,  and  did  not 
rally  from  the  operation.  At  the  post-mortem  examina- 
tion the  heart  was  found  to  be  the  seat  of  marked  fatty 
degeneration. 


MINOR   OPERATIONS 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Nature  of  operation 

Cases 

Deaths 

Dilatation  of  cervix — 

For  sterility  and  dysmenorrhoea 
Dilatation  of  cervix  and  curetting — 

498 

0 

For    endometritis, 

retained    products    and 

bleeding 

2,614 

1 

cancer  of  cervix 

J55 

2 

Vaginal  myomectomy 
For  myomatous  polyp 

us 

32 
159 

1 

0 

,,    mucous 
Perineoplasty 
Colpo-perineoplasty 
Colporrhaphy 
Trachelorrhaphy     . 
For  dyspareunia  and 

vaginisi 

nus 

155 
447 
84 
90 
69 
5° 

0 

3 
1 
0 
0 
0 

Carried 

forw 

ard 

4.353 

8 

RESULTS-IMMEDIATE 


693 


MINOR 

OPERATIONS  {continued) 

Nature  of  operation 

Cases 

Deaths 

Brought  forward  . 

4,353 

8 

Amputation  of  cervix    ..... 

24 

0 

Excision  of   vaginal  cyst           .... 

14 

0 

,,        ,,           „       tumour     .... 

M 

0 

,,    Bartholinian  cyst 

67 

0 

abscess 

15 

0 

,,        „     vulva  for  cancer  and  leucoplakia  . 

45 

0 

,,     papilloma 

11 

0 

Urethral  caruncle             ..... 

213 

0 

Excision  of  urethral  mucous  membrane 

3 

0 

Vesico-vaginal  fistula      .... 

13 

0 

Vesico-uterine  fistula 

1 

0 

Recto-vaginal  fistula 

4 

0 

Periurethral  abscess 

2 

0 

Haematocolpos 

4 

0 

Pyocolpos 

• 

1 

0 

Haematometra 

1 

0 

For  prolapse  (Wertheim) 

. 

2 

0 

Pyometra 

I 

0 

4,788 

8 

CAUSES    OF    DEATH 
Pulmonary  embolism 
Pyaemia      .... 
Septicaemia 
Alcoholic  neuritis 
Bronchitis  and  pneumonia 


Remarks. — In  the  cases  of  perineoplasty,  one  patient 
died  of  pulmonary  embolism,  one  of  alcoholic  neuritis 
several  weeks  after  the  operation,  and  one  of  pyaemia,  the 
source  of  which  was  not  traced.  The  three  cases  of  curet- 
ting died  of  bronchitis  and  broncho-pneumonia.  That  opera- 
tions on  the  perineum  should  have  furnished  one-half  of  the 
deaths  following  minor  operations  is  noteworthy.  This 
operation  involves  opening  up  a  large  number  of  veins. 


694 


GYNECOLOGICAL  SURGERY 


RESULTS    OF    ALL    MAJOR    OPERATIONS 

Middlesex  Hospital  and  Chelsea  Hospital  for  Women, 
January,  1895 — August,  1910,  inclusive 


Number  of  cases 

Number  of  deaths 

Mortality-rate 

4,534 

199 

4-3   % 

Chelsea  Hospital  for  Women,  January,  1905 — August, 
1910,  inclusive 


Number  of  cases 

Number  of  deaths 

Mortality-rate 

1,670 

38 

2-2     % 

CAUSES    OF    DEATH 

Peritonitis        .... 

■        52 

Shock     ..... 

33 

Intestinal  obstruction 

22 

Pulmonary  embolism 

13 

Organic  heart-disease 

13 

Postoperative  haemorrhage 

12 

Preoperative  sepsis  . 

3 

Broncho-pneumonia 

3 

Thrombosis  of  inferior  vena  cava 

2 

Gangrene  of  the  bowel 

2 

Hyperpyrexia 

1 

Syncope            .... 

1 

Delirium  tremens 

1 

Acute  delirious  mania 

1 

Secondary  growths  . 

1 

Iodoform  poisoning 

1 

Anaesthetic  poisoning 

1 

Perforated  gastric  ulcer 

1 

Carcinoma  of  the  pylorus 

1 

Cerebral  embolism    . 

1 

Cerebral  haemorrhage 

1 

Diabetic  coma 

1 

Psoas  abscess 

1 

No  post-mon 

em 

3i 

199 


CHAPTER     XLI 

REMOTE    RESULTS    OF    OPERATIONS    ON    THE 
FEMALE    GENITAL    ORGANS 

While  the  remote  results  of  gynaecological  surgery  are 
often  brilliant  and  commonly  admirable,  in  a  small  minority 
of  cases  they  are  disappointing,  and  that  not  from  any 
fault  in  the  technique  or  failure  of  the  patient  to  recover 
immediately  from  the  operation  with  a  satisfactory  con- 
valescence. 

It  must  be  remembered  that  the  patient  may  be  the 
subject  of  some  disease  in  addition  to  that  present  in  the 
pelvic  organs,  and  that  an  operation,  though  successful  as 
far  as  the  pelvic  condition  is  concerned,  may  not  entirely 
alleviate  all  the  symptoms  of  which  she  complains. 

It  is  the  possibility  of  this  failure  to  cure,  much  more 
than  the  actual  risk  of  the  operation,  that  at  times  deters 
the  experienced  surgeon  from  advocating  strongly  what 
he  feels  is  the  best  treatment.  j 

The  surgeon,  with  the  rest  of  mankind,  tends  to  mag- 
nify his  successes  and  minimize  his  failures.  This,  after 
all,  is  only  human  nature,  and  yet  a  report  by  a  surgeon 
of  his  failures  would  often  be  of  much  more  use  than  a 
whole  string  of  striking  successes. 

The  young  and  enthusiastic  surgeon  undertakes  a 
case  in  the  almost  certain  belief  of  a  perfect  ultimate  result ; 
and  if  the  patient  recovers,  convalesces,  and  disappears 
from  his  notice,  he  accounts  the  case  one  of  his  successes. 
Work  in  an  out-patient  department  for  a  few  years  will 
lessen  such  confidence.  We  do  not  mean  for  an  instant  to 
question  the  splendid  work  and  brilliant  results  of  surgeons 
at  the  present  time,  but  we  do  wish  to  insist  on  the  fact 

695 


696  GYNECOLOGICAL  SURGERY 

that  the  mere  performance  of  an  operation,  although 
apparently  successful,  is  not  always  followed  by  the  relief 
which  might  reasonably  have  been  anticipated.  Although, 
as  we  shall  see  from  the  reports  of  Arthur  Giles  about  to 
be  quoted,  the  surgeon  is,  in  the  main,  justified  in  his 
contention  that  in  the  majority  of  cases  a  cure  results, 
and  in  most  of  the  remainder  marked  relief  is  obtained 
from  very  distressing  symptoms,  the  following  may  be 
accounted  as  some  of  the  failures  which  occasionally  occur 
in  the  practice  of  pelvic  surgery  in  the  female  : — 

Scar  -  hernia.  —  Hernia  due  to  the  stretching  of  an 
abdominal  wound  may  be  the  cause  of  much  suffering,  and 
may  appear  first  after  several  years.  This  condition  has 
been  fully  referred  to  in  Chapter  xxxvu.,  p.  637. 

We  think  it  is  probable  that  the  majority  of  those 
patients  who  suffer  from  a  scar-hernia  will  return  to  the 
institution  where  the  operation  was  performed.  A  few 
will  put  up  with  the  condition,  a  few  may  seek  advice 
elsewhere,  but  most  will  return.  We  find  that  during 
the  last  fifteen  years  72  patients  have  been  admitted  to 
the  Chelsea  Hospital  for  Women  for  an  operation  necessi- 
tated by  scar-hernia,  and  during  this  time  3,786  patients 
have  recovered  from  an  abdominal  operation. 

Keloid  of  the  scar. — Very  rarely  there  may  be  a  keloid 
development  in  the  scar.  We  have  seen  one  such  case. 
The  keloid  is,  as  a  rule,  not  very  excessive,  and,  apart 
from  a  slight  pruritus,  causes  no  trouble. 

Carcinoma  of  the  scar.  —  Implantation  -  metastases 
rarely  occur  in  the  abdominal  wound.  We  have  seen  few 
cases.  The  condition  has  generally  followed  the  removal  of 
a  malignant  ovarian  tumour. 

Pain. — Patients,  after  the  abdomen  has  been  opened, 
will  at  times  complain  of  pain  in  an  apparently  healthy 
scar,  more  particularly  if  silkworm-gut  sutures  have  been 
used ;  whilst  chronic  abdominal  pain,  due  to  intestinal 
adhesions  or  to  irritation  by  the  ligature  in  the  stump  of 
the  pedicle  after  an  ovariotomy,  hysterectomy,  or  removal 


RESULTS-REMOTE  697 

of  diseased  appendages,  is  an  occasional  sequela  of  these 
operations. 

Constipation  and  flatulence. — These  occasionally  give 
rise  to  great  discomfort,  and  are  often  due  to  adhesions 
between  the  intestines,  omentum,  and  parietes.  There  can 
also  be  no  doubt  that  the  opening  of  the  peritoneal  cavity 
alters,  perhaps  permanently,  the  pressure  conditions  that 
have  previously  obtained  there,  and  it  is  probable  that  the 
flatulence  and  unpleasant  consciousness  of  intestinal  peri- 
stalsis that  affect  all  patients  more  or  less  for  a  time  after 
abdominal  operations  are  due  to  this  cause. 

Painful  micturition. —  It  is  a  well-known  fact  that 
many  women  who  have  had  the  catheter  passed  even  once 
after  an  operation  will  complain  for  a  long  while  subse- 
quently of  pain  at  the  end  of  micturition,  and  this  quite 
apart  from  cystitis.  In  other  cases,  adhesions  between 
the  bladder  and  neighbouring  parts  or  displacement  of 
that  viscus  are  the  cause  of  this  discomfort. 

Dyspareunia. — After  panhysterectomy,  and  more  espe- 
cially after  the  radical  operation  for  cancer  of  the  cervix, 
dyspareunia  may  occur  from  shrinkage  or  shortening  of 
the  vagina.  Where  extensive  pelvic  peritonitis  has  existed 
before  the  operation,  or  arises  after  it,  permanently  tender 
adhesions  in  the  pelvis  may  be  responsible  for  the  same 
complaint. 

Dyspareunia  may  also  be  due  to  the  atrophic  condition 
of  the  vulva  associated  with  stenosis  of  the  vaginal  orifice 
known  as  kraurosis  vulvae,  which  occasionally  follows  re- 
moval of  the  ovaries.     We  have  seen  one  such  case. 

Retroversion  of  the  uterus  after  the  removal  of 
the  diseased  appendages.  —  It  sometimes  happens  that, 
some  months  after  an  operation  for  the  removal  of  diseased 
Fallopian  tubes,  and  more  especially  if  the  operation  was 
of  a  severe  nature  necessitating  the  separation  of  many 
adhesions  and  the  consequent  formation  of  a  raw  surface 
in  Douglas's  pouch,  the  patient  will  return  and  state  that 
she  feels  quite  as  bad  as  ever.     She  has  pain  on  defalcation, 


698  GYNECOLOGICAL  SURGERY 

dysmenorrhoea,  dyspareunia,  backache,  and  perhaps  inter- 
ference with  micturition.  A  vaginal  examination  dis- 
closes the  fact  that  the  uterus  is  retroverted,  tender,  and 
fixed.  This  could  have  been  obviated  by  ventro-suspen- 
sion  of  the  uterus  at  the  first  operation,  a  procedure  we 
now  almost  invariably  follow  when  dealing  with  this  class 
of  case.     This  matter  is  referred  to  at  p.  438. 

Failure  to  cure  symptoms. — 1.  The  commonest  opera- 
tion for  leucorrhcea  or  menorrhagia  is  curettage  ;  but  it 
is  sometimes  a  disappointing  operation,  especially  when 
carried  out  for  excessive  menstrual  loss.  It  is  a  mistake, 
therefore,  to  hold  out  too  strong  hopes  with  this  opera- 
tion ;  rather  should  the  patient  be  warned  that,  although 
it  is  the  treatment  most  suitable  to  her  case,  yet  the  results 
are  sometimes  disappointing. 

2.  Virginal  dysmenorrhoea  is  usually  cured  by  dilat- 
ing the  cervix,  but  in  a  certain  number  of  cases  it  fails  to 
be  thus  relieved.  It  may  be  that  it  will  be  cured  at  a 
second  attempt,  or,  on  the  other  hand,  it  may  be  incur- 
able by  any  method  short  of  inducing  the  menopause  by 
subtotal  hysterectomy.  It  is  most  necessary,  when  advis- 
ing these  patients  to  undergo  dilatation  of  the  cervix,  to 
inform  them  of  the  possibility  of  failure. 

3.  An  extensive  acquaintance  with  the  operation  of 
ventro-suspension  for  the  condition  of  prolapse  of  the 
uterus,  as  performed  by  others  as  well  as  ourselves,  led  us 
long  ago  to  discard  it  for  the  relief  of  the  symptoms  com- 
plained of,  unless  combined  with  perineoplasty.  Attend- 
ance in  the  out-patient  department  will  disclose  women, 
upon  whom  this  operation  has  been  performed,  returning 
with  the  statement  that  they  are  no  better,  and  an  examina- 
tion will  show  the  cause  of  their  complaint ;  for  whereas  the 
uterus  is  fixed  in  good  position,  the  prolapse  of  the  vaginal 
walls,  with  which  the  original  condition  was  associated, 
remains.  Ventro-suspension  for  prolapse  should  only  be 
performed  in  combination  with  perineoplasty,  and,  if  need 
be,  colporrhaphy  as  well. 


RESULTS— REMOTE  699 

The  return  of  symptoms — After  a  successful  operation 
the  symptoms  for  which  it  was  performed  may  recur.  The 
following  are  examples  of  this  misfortune  :  — 

1.  The  fact  that  when  performing  a  myomectomy  no 
other  myoma  could  be  seen  or  felt  is  no  assurance  that 
none  others  will  appear  later  on. 

2.  Many  a  woman  has  failed  to  get  permanent  relief 
after  the  removal  of  a  diseased  Fallopian  tube  or  ovary 
on  one  side,  owing  to  that  on  the  opposite  side  becoming 
disorganized  later. 

3.  That  a  woman  has  had  tubal  gestation  on  one  side 
is  no  reason  why  the  other  side  should  not  be  similarly 
affected  later  on.  In  about  5  per  cent,  of  the  cases  the 
disease  occurs  on  both  sides  sooner  or  later. 

4.  Both  the  ovaries  of  a  woman  may  grow  tumours, 
and  that  at  different  times. 

5.  Occasionally  the  adhesion  between  the  uterus  and 
abdominal  parietes  due  to  a  ventro-suspension  breaks  or 
so  stretches  that  the  operation  is  a  failure. 

6.  Dilatation  of  the  cervix  for  virginal  dysmenorrhea, 
though  at  first  successful,  may  not  be  permanently  so,  the 
pain  returning  after  the  lapse  of  some  months  or  more. 
The  dilatation  should  then  be  repeated. 

Menopausal  symptoms. — If  the  ovaries  are  removed, 
such  symptoms  as  headache,  weakness,  flushings  of  heat, 
sensation  of  cold;  dimness  of  vision,  nausea,  etc.,  may  be 
very  troublesome  and  last  for  quite  a  long  while.  These 
symptoms  may  come  on  acutely  or  gently,  the  former 
being  the  most  troublesome.  The  treatment  of  these 
menopausal  symptoms  is  usually  difficult.  We  have 
found  potassium  bromide  and  nux  vomica  to  be  the  most 
generally  useful  combination  of  drugs.  Ovarian  extract 
has  in  our  hands  been  an  absolute  failure. 

Neurosis.  —  Every  surgeon  has  had  experience  of  the 
neuroses  following  operations.  Their  manifestations  are 
protean ;  nothing  abnormal  can  be  detected,  and  no  treat- 
ment is  for  long  of  any  avail.     Tonics,  bromides,  change 


700  GYNECOLOGICAL  SURGERY 

of  air  and  scene,  high-frequency  currents,  massage,  and 
Weir-Mitchell  treatment  should  be  severally  tried  accord- 
ing to  the  peculiarities  of  the  case. 

The  question  of  sanity  and  mental  instability  has  already 
been  discussed  (p.  665). 

Convalescence. — The  more  ill  a  patient  has  been  before 
a  successful  operation,  the  sooner,  other  things  being 
equal,  will  she  be  gratified  with  its  results.  But  after  any 
major  operation  it  is  well  to  impress  upon  the  patient 
that,  even  if  she  makes  what  is  considered  a  normal  con- 
valescence, she  will  not  appreciate  its  full  benefit  until 
the  best  part  of  twelve  months  has  elapsed.  It  takes, 
roughly,  three  months  to  recover  her  physical  and  mental 
balance,  six  months  to  begin  to  feel  the  improvement 
wrought  by  the  operation,  and  twelve  months  before  the 
new  lease  of  life  and  health  is  fully  entered  on  and  the 
recollection  of  the  illness  fades  away  into  the  past  like 
the  memory  of  an  evil  dream. 

The  above  remarks  on  the  "  remote  results  "  of  opera- 
tions are  the  outcome  of  our  personal  experience,  much 
of  which  has  been  gained  from  work  in  the  out-patient 
department,  where  we  had  opportunities  from  time  to 
time  of  examining  patients  upon  whom  some  operation 
had  previously  been  performed.  It  is  evident  that  the 
knowledge  thus  obtained  is  only  partial,  because,  in  the 
first  place,  the  average  out-patient,  when  cured,  takes 
no  further  interest  in  the  hospital  or  surgeon  ;  secondly, 
even  if  she  wished  to  report  herself,  the  expense  and  trouble 
of  doing  so  act  as  a  sufficient  deterrent  ;  thirdly,  the 
only  patients  one  is  likely  to  see  are  those  who  have  not 
received  all  the  benefits  they  anticipated  ;  and,  finally,  a 
certain  percentage  even  of  these,  failing  to  obtain  relief 
at  one  hospital,  will  seek  advice  at  another  in  the  hope 
of  better  success.  Our  colleague  at  the  Chelsea  Hospital 
for  Women,  Arthur  Giles,  has,  however,  published*  a  paper 

*  Journal  of  Obstetrics    and   Gynecology    of   the  British  Empire,    xvii., 
Nos.   3  to  6,  and  xviii.,   No.   1.     The  papers  have  since  been  published  in 


RESULTS— REMOTE  701 

on  remote  results,  far  more  complete  than  anything  that 
had  previously  appeared  in  print.  He  most  kindly  placed 
his  results  at  our  disposal,  and  we  are  thus  able  to  give 
the  conclusions  he  arrived  at  after  his  very  exhaustive 
and  critical  investigation  into  the  "  after-results  of  abdo- 
minal operations  on  the  pelvic  organs,  based  on  a  series 
of  1,000  consecutive  cases."  For  this  purpose  printed 
forms,  comprising  a  large  number  of  questions  dealing  with 
the  health  and  condition  of  the  patient  after  her  operation, 
were  sent  to  each  patient  ;  and  in  addition,  where  possible, 
the  patient  was  examined,  or,  if  this  was  impossible,  the 
medical  attendant  was  asked  to  fill  up  "  the  present  condi- 
tion." The  reports  have  been  collected  for  over  ten  years, 
and  form  the  most  important  contribution  to  this  subject 
that  has  yet  appeared. 

This  report  is  particularly  interesting  to  us  since  a 
large  portion  of  it  deals  with  the  after-results  to  patients 
who  have  been  operated  upon  at  the  Chelsea  Hospital  for 
Women,  at  which  institution  we  have  gained  much  of  the 
experience  that  has  encouraged  us  to  write  this  book. 

The  following  are  Giles's  conclusions,  as  set  out  by  him 
under  the  various  operations  : — ■ 

After-Results    of    Operations    for   the    Removal   of 

Appendages  of  One  Side 

Number  of  cases,  284.     Percentage  of  cases  traced,  80  "6. 

1.  Speaking  generally,  operations  for  the  removal  of 
the  appendages  of  one  side  have  no  detrimental  effect  on 
the  general  health,  the  cases  where  ill-health  could  be 
traced  to  the  operation  numbering  not  more  than  5  per 
cent.  About  90  per  cent,  of  cases  were  actually  better 
after  the  operation  than  they  were  before. 

2.  The  relief  of  symptoms  is  well  marked  after  these 
operations  ;  about  8y  per  cent,  of  patients  were  free  from 
pain  afterwards,  or  experienced  less  pain  than  before  the 

book  form  under  the  title  of  "  A  Study  of  the  After-Results  of  Abdominal 
Operations."     (Bailliere,  Tindall  and  Cox.) 


702  GYNECOLOGICAL  SURGERY 

operation,  whilst  a  further  5  per  cent,  were  free  from  pain 
for  a  time  and  developed  pain  later  from  other  causes. 
Dyspareunia,  dysmenorrhcea,  menorrhagia,  and  leucor- 
rhcea  were  relieved  in  a  number  of  cases. 

3.  The  removal  of  the  appendages  of  one  side  was 
followed  by  irregularity,  diminution,  or  cessation  of  men- 
struation in  a  small  number  of  cases  (8),  and  in  6  cases 
there  followed  a  diminution  of  the  sex-instinct. 

4.  The  chances  of  the  disease  developing  in  the  remain- 
ing ovary  and  tube  are  not  very  great  ;  such  a  recurrence 
took  place  in  about  10  per  cent,  of  cases.  Consequently, 
in  view  of  the  definite  value  of  the  remaining  ovary  and 
tube,  it  is  always  worth  while  preserving  them  when  they 
appear  to  be  healthy.  Soiling  of  the  peritoneal  cavity 
with  the  contents  of  an  ovarian  cyst  favours  the  occur- 
rence of  later  disease,  and  therefore  the  interests  of  the 
patients  are  safeguarded  by  the  removal  of  these  cysts 
(however  large)  intact  without  tapping. 

5.  The  remaining  tube  and  ovary  have  a  considerable 
value  from  the  point  of  view  of  subsequent  pregnancy  ; 
33  patients,  or  25  per  cent.,  of  the  married  women  under 
40  became  pregnant.  Of  these  19  had  full-time  deliveries 
(some  repeated),  5  had  miscarriages,  and  7  had  extra-uterine 
pregnancy,  while  2  were  pregnant  when  seen.  It  would 
appear  that  after  the  removal  of  appendages  of  one  side 
there  is  a  greater  liability  to  the  occurrence  of  extra-uterine 
pregnancy  than  is  the  case  with  normal  women. 

The  19  women  who  had  full-time  pregnancies  bore 
between  them  25  children,  and  4  more  children  were 
born  at  full  time  when  ovariotomy  was  undertaken  during 
pregnancy. 

A  study  of  the  sex  of  these  children  in  relation  to  the 
side  on  which  the  remaining  or  active  ovary  was  situated 
definitely  refutes  the  theory  that  right  ovaries  produce 
boys  and  left  ovaries  produce  girls ;  it  shows  clearly 
that  there  is  no  relation  between  the  side  from  which  the 
ovum  is  derived  and  the  sex  of  the  child. 


RESULTS— REMOTE  703 

After-Results  of  the  Removal  of  Both  Appendages 
Number  of  cases,  277.     Percentage  of  cases  traced,  76*6. 

1.  The  removal  of  both  ovaries  and  tubes  has  no  marked 
detrimental  effect  on  the  subsequent  health,  for  78  per 
cent,  of  the  patients  were  in  very  good  health  afterwards, 
and  a  further  13  per  cent.,  though  suffering  in  different 
ways,  were  better  than  before  the  operation,  making  in  all 
91  per  cent,  who  were  quite  well  or  at  least  improved.  The 
condition  of  the  general  health  is  even  better  than  it  is 
after  unilateral  salpingo-oophorectomy. 

2.  The  likelihood  of  later  trouble  developing  in  con- 
nexion with  the  uterus  when  the  organ  is  left  is  relatively 
small,  as  such  an  occurrence  took  place  in  only  7  cases  out 
of  105.  It  is  therefore  worth  while  leaving  the  uterus  in 
all  cases  where  it  appears  to  be  healthy.  The  removal  of 
the  uterus  seems  to  increase  the  immediate  risk  of  the 
operation  in  inflammatory  cases. 

3.  Menstruation  continued  after  these  operations  in 
about  40  per  cent,  of  the  cases,  the  proportion  being  largest 
in  cases  where  the  operation  was  done  for  inflammatory 
disease.  When  menstruation  persisted  after  ovariotomy 
for  tumours  it  was  mostly  in  cases  where  the  tumours  were 
parovarian  or  intraligamentary.  The  inference  is  that 
some  portion  of  ovarian  tissue  had  remained  behind  in 
these  cases. 

4.  The  characteristics  of  the  artificial  menopause  pro- 
duced by  the  complete  removal  of  both  ovaries  are  as 
follows  : — 

(1)  Flushes  of  heat  come  on  within  three  months 
of  the  operation  in  80  per  cent,  of  the  cases,  and  within 
a  month  in  55  per  cent. 

(2)  These  flushes  commonly  last  for  several  years, 
and  may  go  on  as  long  as  ten  years.  Probably  the 
average  duration  would  be  three  or  four  years. 

(3)  The    majority    of   patients    retain   their   bodily 


704  GYNECOLOGICAL  SURGERY 

vigour  and  energy,  namely,  about  72  per  cent.  ;  28  per 
cent,  are  easily  tired,  or  complain  of  lack  of  energy. 
This  may  be  partly  due  to  the  fact  of  an  abdominal 
operation,  as  distinct  from  the  influence  of  the  meno- 
pause. 

(4)  The  influence  of  the  artificial  menopause  in 
causing  mental  depression  is  relatively  small,  amount- 
ing to  about  10  per  cent,  of  the  cases. 

(5)  In  a  large  proportion  of  cases  the  sex-instincts 
are  not  affected  ;  in  68  per  cent,  they  were  either  un- 
affected or  increased,  in  16  per  cent,  they  were 
diminished,  and  in  a  further  16  per  cent,  they  were 
lost. 

(6)  The  artificial,  like  the  natural  menopause,  is 
followed  by  some  atrophy  of  the  uterus  and  vagina, 
but  not  in  all  cases  ;  62  per  cent,  showed  some  change 
within  two  years,  73  per  cent,  within  five  years,  and 
82  per  cent,  when  more  than  five  years  had  elapsed. 
Many  patients  showed  a  tendency  to  obesity,  but  this 
effect  is  not  so  marked  as  after  the  natural  menopause. 
There  is  no  foundation  for  the  view  that  the  removal 
of  the  ovaries  leads  to  the  development  of  masculine 
characteristics,  such  as  growth  of  hair  on  the  face, 
atrophy  of  the  breasts,  and  a  deepening  of  the  voice, 
except,  perhaps,  in  cases  where  the  operation  is  done 
before  or  about  the  age  of  puberty. 

After-Results  of  Hysterectomy  for  Uterine  Myomata 

and  Fibrosis 

Number  of  cases,  228.     Percentage  of  cases  traced,  85*3. 

1.  The  effect  on  the  general  health  of  hysterectomy 
for  myomata  is  very  satisfactory,  inasmuch  as  70  per  cent, 
of  the  patients  were  in  very  good  health  after  the  opera- 
tion, and  as  many  as  96  per  cent,  were  better  than  before 
the  operation. 

2.  The  fate  of  the  cervical  stump  after  supravaginal 
hysterectomy  need  cause  no  apprehension  ;    in   180   cases 


RESULTS— REMOTE  7°5 

there  was  not  one  that  showed  any  sign  of  malignancy,  and 
in  98*3  per  cent,  there  was  no  trouble  of  any  kind.  In 
cases  of  fibrosis,  however,  it  is  important  either  to  do  a 
panhysterectomy,  or  at  least  to  make  sure  that  the  whole 
of  the  body  of  the  uterus  is  removed,  as  a  small  portion  of 
it  may  keep  up  haemorrhage. 

3.  After  supravaginal  hysterectomy,  menstruation,  or 
at  least  a  monthly  discharge  of  blood,  may  take  place  if 
only  a  small  portion  of  the  body  of  the  uterus  has  been 
left  behind. 

4.  The  cessation  of  menstruation  after  hysterectomy, 
with  preservation  of  one  or  both  ovaries,  is  an"  apparent " 
menopause ;  the  constitutional  changes  incidental  to  the 
true  menopause,  as  indicated  by  heat  flushes,  are  delayed 
from  one  to  several  years  in  these  cases.  Nevertheless, 
the  removal  of  the  uterus  brings  about  the  true  menopause 
a  good  deal  earlier  than  the  usual  time. 

5.  After  hysterectomy,  with  preservation  of  the  ovaries, 
there  is  some  diminution  of  the  sex-instinct  in  about  20 
per  cent,  of  the  cases  ;  but  the  sex-instinct  is  practically 
never  lost  altogether. 

After-Results   of   Hysterectomy   for  Carcinoma 
Number  of  cases,  21.     Percentage  of  cases  traced,  79. 

1.  The  results  of  hysterectomy  for  carcinoma  of  the 
body  of  the  uterus  are  very  good,  as  all  6  cases  traced 
showed  no  sign  of  recurrence  after  periods  varying  from 
8  months  to  3  years. 

The  results  of  hysterectomy  for  carcinoma  of  the 
cervix  are  satisfactory,  as  far  as  the  recent  character  of 
most  of  the  cases  allows  of  deductions,  since  7  out  of  9 
cases  showed  no  recurrence  after  periods  varying  from 
6  months  to  2\  years. 

2.  The  effects  on  the  general  health  are  very  good,  as  all 
the  patients  were  better  after  the  operation,  and  8  out  of 
13  were  in  very  good  health. 

2  T 


7o6  GYNECOLOGICAL  SURGERY 

After-Results  of  Abdominal  Myomectomy 

Number  of  cases,  51.     Percentage  of  cases  traced,  81 '6. 

The  following  deductions  are  permissible  as  to  the  value 

and  scope  of  myomectomy  versus  hysterectomy  for  fibroids. 

It  may  be  laid  down  as  a  general  rule  that  hysterectomy 

is  preferable  to  myomectomy — 

(a)  In  the  case  of  multiple  myomata. 

(b)  In  the  case  of  cervical  myomata. 

(c)  In  the  case  of  a  single  large  interstitial  or 
intra-uterine  myoma  in  women  over  40. 

(d)  When  interstitial  or  subperitoneal  myomata  are 
associated  with  haemorrhage,  making  it  probable  that 
intra-uterine  myomata  are  also  present. 

Myomectomy  is   permissible   from   the   operative   point 
of  view  in  the  case  of — ■ 

(a)  Pedunculated  subperitoneal  myomata. 

(b)  Small  interstitial  myomata  when  they  are  not 
more  than  three  or  four  in  number. 

(c)  A  solitary  intra-uterine  myoma,  or  a  fair-sized 
solitary  interstitial  myoma,  in  women  under  40,  and 
more  particularly  in  young  married  women. 

Summing  up  the  conclusions  of  this  section,  it  is  shown 
that— 

1.  The  general  health  after  myomectomy  is  very 
good,  85  per  cent,  of  patients  being  in  quite  good 
health,  or  at  least  better  than  before  the  operation. 

2.  The  likelihood  of  recurrence  of  myomata  is 
relatively  small,  the  cases  amounting  to  under  10  per 
cent.  ;  90  per  cent,  were  free  from  recurrence  after 
periods  varying  from  one  to  seven  years. 

3.  The  menstrual  loss  is  moderate,  or  even  scanty, 
in  about  85  per  cent,  of  cases,  many  of  the  patients 
stating  that  the  loss  was  less  than  before  the  opera- 
tion. 


RESULTS-REMOTE  707 

4.  The  uterus  from  which  myomata  have  been 
removed  may  be  '  serviceable  for  child-bearing,  3 
patients  out  of  15  married  women  under  45  having 
become  pregnant  subsequently  to  the  operation.  The 
uterus  bears  the  strain  of  pregnancy  and  labour  with- 
out difficulty. 

After-Results   of   Operations   for   Uterine 
Displacement 

Number  of  cases,  309.    Percentage  of  cases  traced,  81-5. 

1.  The  effect  of  ventro-suspension  on  general  health  is 
very  good,  as  90  per  cent,  of  the  patients  were  better  than 
before  the  operation,  as  many  as  75  per  cent,  being  in 
quite  good  health  ;  whilst  of  the  10  per  cent,  who  were  not 
better,  in  one-half  of  them  the  cause  had  nothing  to  do 
with  the  operation. 

2.  Symptoms  are  markedly  relieved  :  90  per  cent,  of 
the  patients  either  had  no  pain  afterwards  or  had  less 
pain  than  before  the  operation  ;  14  patients  were  relieved 
of  dysmenorrhcea  ;  21  of  dyspareunia  ;  and  16  of  head- 
aches ;  22  patients  got  relief  from  menorrhagia,  and  13 
from  excessive  leucorrhcea  ;  13  patients  found  their  con- 
stipation improved. 

3.  As  regards  the  effect  of  ventro-suspension  on  the 
bladder,  18  per  cent,  of  patients  experienced  frequency  of 
micturition,  and  77  per  cent,  had  no  trouble,  or  no  more 
than  before  the  operation. 

4.  The  position  of  the  uterus  remains  permanently 
good  in  about  95  per  cent,  of  cases  ;  about  5  per  cent,  suffer 
from  partial  or  complete  return  of  displacement.  The 
results  in  cases  of  procidentia  are  not  quite  so  good  as  in 
cases  of  retroversion  or  prolapse,  but  88  per  cent,  of  cases 
of  procidentia  show  permanent  good  results.  To  obtain 
the  best  results  in  procidentia,  combined  operations  are 
usually  necessary. 

5.  In  the  event  of  pregnancy  following  ventro-suspension, 


708  GYNECOLOGICAL  SURGERY 

there  is  a  slightly  increased  tendency  to  miscarriage  if 
pregnancy  follows  too  soon  after  the  operation.  Ventro- 
suspension  causes  no  subsequent  complications  of  labour, 
as  out  of  44  cases  of  full-time  delivery,  40  had  normal  con- 
finements and  the  remaining  4  had  complications  which 
were  independent  of  the  operation. 

6.  When  pregnancy  follows  ventro-suspension  the  position 
of  the  uterus  is  not  disturbed  thereby,  as  the  results  after 
pregnancy  were  just  as  good  as  in  cases  where  no  preg- 
nancy followed,  and  the  cases  of  full-time  delivery  showed 
only  one  instance  of  partial  return  of  displacement  out  of 
29.  Among  these  cases,  therefore,  the  uterus  kept  in  good 
position  in  o,6'6  per  cent.,  as  against  947  per  cent,  in 
patients  who  did  not  become  pregnant. 

AFTER-RESULTS  OF  ABDOMINAL  OPERATIONS 
IN  GENERAL  ON  THE  FEMALE  GENERATIVE 
ORGANS 

Number  of  cases,  1,000.     Percentage  of  cases  traced,  80. 

This  section  constitutes  in  some  measure  a  summary  of 
those  preceding,  but  there  are  one  or  two  points  to  consider 
that  have  not  been  touched  upon. 

1.  With  regard  to  the  general  health  after  abdominal 
operations,  it  was  found  that  90  per  cent,  of  the  patients 
were  better  than  they  were  before  the  operation,  72  per 
cent,  being  in  quite  good  health  ;  about  6  per  cent,  were 
either  worse,  or  at  least  no  better,  in  many  cases  from 
causes  quite  independent  of  the  operation  ;  and  a  further 
4  per  cent,  had  been  much  better  for  a  time,  and  had 
suffered  lately  from  ill-health  due  to  local  or  general 
causes. 

2.  The  period  of  invalidism  after  abdominal  operations 
is  limited  to  about  three  months  in  60  per  cent,  of  the 
cases  ;  a  further  10  per  cent,  of  the  patients  cease  to  be 
invalids  by  the  end  of  the  first  year  ;  while  30  per  cent, 
are  still  invalids  or  semi-invalids  at  the  expiration  of  that 


RESULTS-REMOTE  709 

period,  though  two-thirds  of  these  eventually  get  quite  well. 
Age  has  a  marked  influence  ;  the  younger  the  patient, 
other  things  being  equal,  the  quicker  the  convalescence. 

3.  The  memory  appears  to  be  affected  in  about  25  per 
cent,  of  cases  after  abdominal  operations.  Further,  the 
deterioration  of  memory  appears  to  be  directly  propor- 
tioned to  the  duration  of  the  operation,  as  in  cases  of  long 
operations  for  uterine  carcinoma  the  memory  was  affected 
in  50  per  cent,  of  the  cases  ;  in  short  operations  for 
hysteropexy  the  proportion  dropped  to  18  per  cent.  ;  and 
operations  of  intermediate  duration  showed  proportionate 
percentages. 

4.  In  64  cases  out  of  770  (8*3  per  cent.)  further  abdominal 
operations  were  required.  About  3  per  cent,  were  necessi- 
tated by  direct  sequelae  of  the  operation,  and  of  these  the 
cases  of  inflammatory  disease  of  the  appendages  supplied 
the  largest  proportion  ;  6  cases  were  necessitated  by  recur- 
rence of  uterine  displacements  ;  and  34  (4*4  per  cent.) 
were  required  for  conditions  independent  of  the  first 
operation.  The  risk  of  subsequent  independent  condi- 
tions requiring  operation  is  greatest  after  unilateral 
salpingo-oophorectomies,  where  it  amounted  to  0/5  per 
cent. 

5.  The  probabilities  of  pregnancy  following  unilateral 
salpingo-oophorectomy  and  conservative  operations  on  the 
uterus  are  good,  as  33  per  cent,  of  married  women  under 
40  among  these  cases  became  pregnant  afterwards ;  73 
per  cent,  of  the  completed  pregnancies  went  to  the  full 
term,  there  were  8  cases  of  extra-uterine  pregnancy, 
and  7  patients  were  pregnant  when  they  were  last  seen. 
Of  60  labours,  55  were  normal,  and  5  had  complications 
that  had  no  reference  to  the  operation.  The  chances  of 
labour  being  normal  after  these  operations  are,  therefore, 
just  as  good  as  in  the  case  of  patients  who  have  had 
no  such  operations. 

6.  Eighty-eight  per  cent,  of  the  patients  had  no  trouble 
at  all  afterwards  with  the  scar;  77  per  cent,  had  stitch- 


7io  GYNECOLOGICAL  SURGERY 

abscesses,  and  3  "6  per  cent,  developed  a  hernia  of  the  scar. 
The  tendency  to  both  complications  is  markedly  greater 
after  operations  for  inflammatory  disease  of  the  appendages  ; 
90  to  93  per  cent,  of  the  "  clean  "  cases  had  no  subsequent 
trouble.  The  tendency  to  stitch-abscess  has  been  dimin- 
ished by  modern  improved  methods,  and  particularly  by 
the  use  of  sterilized  rubber  gloves  during  operations. 


INDEX 


Abdominal  and  vaginal  hysterectomy 
compared,  222 

cavity,  closing,  285 

opening,  276 

difficulties    and    dan- 
gers of,  280 

hysterectomy  {see  Hysterectomy, 

abdominal) 

myomectomy,  413 

after-results  of,   706 

—  causes  of  death  after,  685 
— immediate  results  of,  685 

operations    in     general     on     the 

female     genital     organs, 
after-results  of,  708 

preparation  of  patients  for, 

82,  85 

swabs  for,   25 

section,  dressing  after,   567 

dressings  for,  44 

sinus,  632 

wound,  abscess  of,  629 

bursting  of,   636 

complications  in,   629 

hematoma  of,  629 

size  of,  283 

sloughing  of,  631 

strapping  of,  632 

Abscess  of  abdominal  wound,  629 

of  Bartholin's  gland,  96 

After-results    of    abdominal    myomec- 
tomy,  706 

of  abdominal  operations  in  general 

on  the    female  genital  organs, 
708 

of  hysterectomy  for  carcinoma, 705 

of  hysterectomy  for  uterine  myo- 

mata  and  fibrosis,  704 

of  operations  for  uterine  displace- 
ment, 707 

of  removal  of  appendages  on  one 

side,   701 

of  removal  of    both  appendages, 

703 

After-treatment  routine,  547 

Alcohol  in  sterilization,  33 

Amputation  of  cervix,   177,   181 

immediate  results  of,   693 

Anaesthetic,  complications  due  to,  671 

room,  55 

where  to  administer,  86 

Anaesthetist,  duties  of,  60 

Aneurysm-needle,   17 


Anterior  colporrhaphy,   139 
Antiseptics,   31 

general  remarks  on,  33 

Appendicectomy,  524 
Aseptic  surgery,   31 
Atresia  of  cervix,   153 
Auvard's  speculum,   13 


Baldwin's  method  of  making  an  arti- 
ficial vagina,  129 
Barlow,  Lazarus,  573   (note) 
Bartholinian  cyst,  excision  of,   96 
Bartholin's  gland,   abscess  of,   96 
Basins,   54 

Bearing  of  the  surgeon,   1 
Bed-clothes  during  convalescence,  570 
Bedsores,   670 
Belts,  570 

Berkeley-Bonney  vaginal  clamp,   14 
Berkeley's  infusion  apparatus,  19 
portable  operating  table,  22 

retractor,   12 

scalpel  carrier,  8 

Biniodide  of  mercury,  32 

Bladder,  attention  to  after  operations, 

552 

complications,  postoperative,  654 

hydrostatic  dilatation  of,  94 

implantation  of  cut   ureter  into, 

540 

wounds  of,  538 

Bland-Sutton,  J.,  301 
Blanket  suture,   36 
Blood  lost  during  operation,  592 
Bonney's  clip  retractor,   14 

dissecting  forceps,   8 

hysterectomy,  331 

needles,   17 

Bowel,  postoperative  gangrene  of,  625 

haemorrhage  from,  625 

wounds  of,  545 

Bowels,     treatment    of,     after     major 
operations,   556 

after  minor  operations,  555 

Bowls,  54 

Broad-ligament  cyst  (see  Enucleation) 

myoma,  operation  for,  406 

Bronchitis,  postoperative,  650 
Broncho-pneumonia,  postoperative,  650 
Burns,  anaesthetic,  673 

due  to  hot-water  bottle,   673 

Bursting  of  abdominal  wound,  636 


711 


712 


INDEX 


Ca?costomy,   538 

Cesarean  section,  difficulties  and  dan- 
gers of,  430 

immediate  results  of,  691 

—  indications  for,  421 

sterilization  after,  432 

technique  of,  425 

Canal  of  Nuck,  operation  for  hydrocele 

of,  1 01 
Carbolic  acid,  32 

Carcinoma,    after-results    of    hysterec- 
tomy for,   705 

of  cervix  and  labour,   522 

of  cervix  and  pregnancy,   521 

of  cervix,  causes  of   death  after 

radical  operation  for,  684 
of   cervix,   immediate   results   of 

radical  operation  for,  683 
of     cervix,    Wertheim's     radical 

abdominal  operation  for,   361 

of  scar,  696 

Cardiac  disease  and  operation,   73 
Catgut  ligatures,   23 

dangers  of,  23 

Causes  of  death  after  major  operations, 
694 

Cauterization  for  urethral  caruncle,  87 

Cautery,   Paquelin's,  21 

Cellulitis  after  cervical  dilatation,  168 

postoperative,   605 

Cerebral     haemorrhage,    postoperative, 
667 

thrombosis,  postoperative,  667 

Cervical  carcinoma   (see  Carcinoma  of 
cervix) 

myoma,    anterior,    hysterectomy 

for,   353 

central,  hysterectomy  for, 

340 

general  remarks  on,  338 

hysterectomy  for,  by  hemi- 

section,   350 

hysterectomy  for,  with  enu- 
cleation,  347 

posterior,  hysterectomy  for, 

357 

operations,  dressing  after,   567 

Cervico-vesical  fistula,   183 

Cervix,   atresia  of,   153 

dilatation  of    (see    Dilatation    of 

cervix) 
dressings  for  operations  on,  45 

laceration  of,  whilst  dilating,  160. 

supra-vaginal  amputation  of,  181 

vaginal,  amputation  of,   177 

Chelsea  Hospital  for  Women,  statistics 
of  gynaecological  operations  at,  678 

Chloroform    introduced    into    stomach 
during  anaesthesia,  674 

Circulatory    failure    under    anaesthetic, 
675 

Clamp,  intestinal,   16 

vaginal,   14 

Clip,  retractor,   14 

Clips,  Michel's,   18 

Clitoridectomy,   109 


Clitoris,  removal  of,   109 

Clover's  crutch,   20 

Coccyx,  removal  of,   125 

Colon  tube,  use  of ,  after  operations,  556 

Colotomy,   535 

Colpo-perincoplasty,  immediate  results 

of,   692 
Colporrhaphy,   anterior,   139 

—  dressing  after,  566 

immediate  results  of,  692 

posterior,   r42 

Confinement  to  bed  after  operation,  571 

Consent  of  patient  in  writing,  77 

Constipation  as  after-result  of  opera- 
tion,  697 

postoperative,   626 

Continuous  sutures,   36 

Convalescence,   700 

Costume  of  operator  and  staff,  62 

Counting  of  swabs,   27 

Cross-suture,  36 

Crutch,   Clover's,   20 

Curette,   20 

Curetting,   185 

dangers  of,   189 

dressing  after,  566 

Cushing's  suture,   37 

Cutaneous  eruptions,  postoperative,  667 

Cystitis,  postoperative,  655 

Cysts  of  broad  ligament  (see  Enuclea- 
tion) 

of  vagina,   137 

—  pseudo-broad-ligament,  471 


Death  after  operations  (see  Results, 
immediate) 

Diabetes  and  operation,   74 

Diabetic  coma,  postoperative,  663 

Diarrhoea,  postoperative,   627 

Diet  after  operations,   557 

Dilatation  of  cervix,   154 

of  cervix  and  curetting,  im- 
mediate results  of,   692 

of  cervix,   immediate    results  of, 

692 

of  stomach,  postoperative,   622 

Dilators,  Fenton's,   19 

Directions  to  nurse  after  major  opera- 
tions,  558 

Discharge,   vaginal,   33 

Disrobing-room,   56 

Dissecting  forceps,   8 

Distension,  epigastric,  after  operation, 
586 

flatulent,  after  operation,  586 

paretic,  587 

peritonitic,  589 

—  postoperative,  586 
Douche-pan,   54 
Douching,  vaginal,   33 
Doyen's  hysterectomy,   326 
Drainage,  abdominal  or  vaginal,  47 
management  of,  48 

—  material  for,  48 

—  when  to  employ,  46 


INDEX 


7*3 


Dressings,  565 

for  abdominal  section,   44 

for  vaginal  operations,  45 

Drug-poisoning,  postoperative,  668 
Drugs  after  operation,  570 
Dry  heat,  sterilization  by,  27 
Dyspareunia    and    vaginismus,    imme- 
diate results  of  operations  for, 
692 
as  after -result  of  operation,  697 


Embolism  of  femoral  artery,  622 
of  mesenteric  arteries,  postopera- 
tive,  665 

pulmonary,  postoperative,  651 

Emphysema  of  abdominal  wall,  644 
Enemata,  turpentine,  587 
Enterectomy,  526 

Enucleation  of  broad-ligament  cyst,  463 

of  broad-ligament  cyst,  alterna- 

tives to,  468 

of   broad-ligament   cyst,   dangers 

of,  407 
Eserine,  use  of,  for  intestinal  distension, 

588 
Excision  of  Bartholinian  abscess,   im- 
mediate results  of,  693 

—  of  Bartholinian  cyst,  immediate 

results  of,  693 

—  of    urethral    mucous    membrane, 

693 

of  vaginal  cyst,  immediate  results 

of,  693 

—  of  vaginal  tumour,  immediate  re- 

sults of,   693 
of  vulva,   103 

immediate  results  of,  693 

Extra-uterine  gestation  after  term,  511 
causes  of  death  after  opera- 
tion for,   691 

immediate  results  of  opera- 
tion for,   690 

in  first  three  months,  503 

in  fourth  and  fifth  months, 

508 

in  later  months,   508 


Failure  of  operation  to  cure  symptoms, 

698 
Fallopian  tube,  postoperative  prolapse 

of,   649 
/ tubes,    removal    of,     in    vaginal 

hysterectomy,  252 
Fat-embolism,  postoperative,   653 
Femoral  artery,  embolism  of,  622 

vein,   thrombosis  of,   620 

Fenton's  dilators,   19 

operation  for  vaginismus,    132 

volsella   forceps,    11 

Figure-of-8  suture,  36 
Fistula,  cervico-vesical,   183 

large  intestinal,   634 

recto-vaginal,   152 

small  intestinal,  635 


Fistula,  uretero-abdominal,  659 

urethro- vaginal,   144 

utero -vesical,   184 

vesico-abdominal,    postoperative, 

659 

vesico- vaginal,   145 

Fixation  of  tissues,  49  - 

Flatulence  as  after-result  of  operation, 

697 
Forceps,  dissecting,   8 

Kocher's,   9 

ring,   10 

round-ligament,   n 

shot-and-coil,  11 

Spencer  Wells',  9 

volsella,   11 

Foreign  bodies  left  in  abdomen   after 

operation,  645 
Freund,  W.  A.,  361 
Friends    of    patient,    communications 

to,  76 


General  nurse  at  operations,  duties  of, 
61 

operative  considerations,    1 

Glove-box,   18 

Glover's  stitch  suture,   37 

Gloves,   63 

sterilization  of,  30 

Granny  knot,   38 


Haematocolpos,    immediate    results    of 

operations  for,   693 
Haematoma  of  vulva,  operation  for,  102 

retroperitoneal,  43 

Haematometra,   129,   130 

immediate   results   of   operations 

for,   693 
Haemorrhage,  postoperative,  592 

from  bowel,   625 

from  stomach,   624 

Handle)7,  Sampson,  362 
Hands,  sterilization  of,  34 
Haultain's      operation      for      inverted 

uterus,  450 
Health  of  operating  staff,  61 
Heart  failure,  postoperative,  616 
Hernia  of  scars,   637 
Hiccough,  postoperative,   623 
Hot-water  bottle,  burns  due  to,  673 
Hydrocele  of  canal  of  Nuck,   excision 

of,   1 01 
Hydrogen,  peroxide,  33 
Hydronephrosis,  postoperative,   662 
Hydrostatic  dilatation  of  bladder,  94 
Hymen,    imperforate,     operation     for, 

94 
Hyperpyrexia,  postoperative,  617 
Hysterectomy,  abdominal  and  vaginal, 
compared,  222 

subtotal,    causes    of    death 

after,  681 
immediate  results  of, 


7H 


INDEX 


Hysterectomy,  abdominal  total,  by 
Bonney's  method, 
33i 

; by   Doyen's   method, 

326 

by    routine    method, 

319 

by    routine    method, 

difficulties  and  dan- 
gers, 323 

causes  of  death  after, 

680 

immediate  results  of, 

679 

and  ovariotomy,  462 

by      hemisection      for      cervical 

myoma,  350 

for  anterior  cervical  myoma,  353 

for  broad-ligament  myoma,    406 

for  central  cervical  myoma,  340 

total,  347 

for  posterior  cervical  myoma,  357 

for  uterine  myomata  and  fibrosis, 

after-results  of,  704 

general  considerations,   212 

in  double  appendage  disease,  488 

indications  for,  212 

or  myomectomy,  5 1 8 

subtotal  and  total,  compared,  218 

by  routine  clamp   method, 

292 

by  routine  ligature  method, 

309 

by  routine  ligature  method, 

difficulties  of,  314 

difficulties  of,  307,  314 

vaginal,  by  clamp  method,  259 

by     clamp     and     ligature 

method,  253 

by  ligature  method,  227 

by  ligature  method,  dangers 

of,  248 
by    ligature    method,    diffi- 
culties of,  241 
—  causes  of  death  after,  683 

dressing  after,  567 

—  immediate  results  of,   682 

with     enucleation     for     cervical 

myoma,   347 

with  salpingo-oophorectomy,  316 

Hystero-vaginectomy    by   paravaginal 
section,    dangers    and    difficulties 
of,  270 
radical,  26: 


Immediate-preparation  room,  55 
Immediate  results  {see  Results,  imme- 
diate) 
Imperforate  hymen,  operation  for,  94 
Incontinence    of    urine,    postoperative, 

658 
Infusion  apparatus,  19 
Insanity  after  operation,   665 

and  operation,   75 

Insomnia  alter  operation,  591 


Instrument  nurse,  duties  of,  60 
Instruments,   7 

care  of,  after  operations,  547 

for  abdominal  section,  276 

simplicity  in,   7 

Interrupted  sutures,  35 
Intervesico-vaginal  fixation  of  uterus, 

207 
Intestinal  clamp,  16 

obstruction,  postoperative,   606 

organic,   607 

paretic,   613 

Intraperitoneal    shortening    of    round 
ligaments,  443 

of  round  ligaments,  dangers 

of,  449 
of    round    ligaments,     im- 
mediate results  of,  689 
Intra-uterine  packing,  45 
Intravenous  saline  injection,  573 
Invaginating  suture,  37 
Inversion  of  uterus,  450 
Iodine  for  skin  sterilization,  33 
Irremovable  ovarian  cysts,    treatment 
of,  461 


Jaundice,  postoperative,  667 

Keloid  of  scar,   696 

Kidney    complications,    postoperative 

660 
Knots,   38 

security  of,  23 

Kocher's  forceps,  9 


Leitch,  Archibald,  369,  371 
Lembert's  continuous  suture,   36 

interrupted  suture,  36 

Ligature  material,  23 

shot-and-coil,   n 

Ligatures,  absorbability  of,  23 

occluding   and   suboccluding,    41 

Local  antisepsis  in  major  operations,  83 
Lock  wood's  spirit  solution,  32 
Lung,  postoperative  gangrene  of,  651 
Lysol,  33 

MacCormac  on  glandular  deposits,  371 
Major  operations,  causes  of  death  after, 

694 

dressing  after,  567 

immediate  results  of,  679- 

92,  694 

preparation  of  patient  for,  82 

Manipulation,  operative,   5 

Masks,   63 

Mattress  suture,  36 

Mayo's  scissors,   n 

Menopausal  symptoms  after  operation, 

699 
Mercury  biniodide,  32 

perchloride,  32 

Michel's  clips,   18 


INDEX 


7i5 


Michel's  clips,  advantages  of,  288 

application  of,  289 

removal  of,  291 

Micturition,  painful,  postoperative,  655 
Middlesex  Hospital,  statistics  of  gynae- 
cological operations  at,  678 
Minor  operations,  causes  of  death  after, 

693 

dressing  after,   565 

immediate  results   of,    692, 

693 

preparation  of  patient  for,  78 

Miscarriage  after  operations,  670 

■  after   ovariotomy,   513 

Morphia,  use  of,  after  operation,  513, 

518,  590,  592 
Mucous  polypus,  immediate  results  of 

operations  for,  692 

of  body,   195 

of  cervix,   195 

Myoma  and  labour,   518 

and  pregnancy,  516 

and  puerpery,  519 

—  broad-ligament,  406 

—  injury  to  capsule  of,  in  dilatation 

of  cervix,   168 

of  vagina,  135 

submucous,  enucleation  of,  203 

morcellation  of,   206 

Myomatous  polypus,  immediate  results 
of  operations  for,  159,  692 
—  of  body,   199 

of  cervix,   197 

Myomectomy,  abdominal,  413 
or  hysterectomy,  518 


Needle,  aneurysm,   17 

box,   17 

Worrall's,   17 

Needles,   Bonney's,   17 

curved,   17 

straight,   17 

Nephritis,  postoperative  acute,  660 
Neurosis   as   after-result   of   operation, 

699 
Non.-pedunculated  myoma,  418 
Nurse,  directions  to,   75 
Nurses,  preparation  of,  at  operation,  85 
Nurses'  store-room,  56 
Nursing  chart  for  cases  of  abdominal 

section,   558 


Occupation,  resumption  of,  after  opera- 
tion, 571 
Operating,  speed  in,  4 

suite,  51 

tables,  21,  52 

theatre,  51 

plan  of,  52 

Operation  for  absence  of  vagina,   127, 
129 

for  anterior  cervical  myoma,  353 

for  atresia  of  cervix,   153 

for  atresia  of  vagina,   127 


Operation  for  Bartholinian  abscess,  96 

for  Bartholinian  cyst,  96 

for  bleeding  myoma,  476 

for  broad-ligament  cyst,  463,  468 

for     broad-ligament      cyst      and 

myoma,  218 

for  broad-ligament  myoma,  406 

for  cancer  of  vulva,   103 

for  carcinoma  of  cervix,  361 

fol    carcinoma  of  tube,  217 

for  central  cervical  myoma,  340 

for  cervical  carcinoma,  261 

for  cervical    myoma,    340,    347, 

353>  357 

for  cervicitis,   185 

for  cervico-vesical  fistula,   183 

for  congenital  elongation  of  cer- 

vix,  177 
for  cystocele,   109,   139,   142 

for  defects  of  uterus,  212 

for  deformity  of  uterus,  319 

for  delivery  of  foetus,   421 

for  dysmenorrhoea,  476 

for  extra-uterine  gestation,  503 

for  fibrosis,  319 

for  hasmatoma  of  vulva,   102 

for  hamatometra,   129,   130 

for  hsemato-salpinx,  476,  499 

for  hydrocele  of  canal  of  Nuck, 

101 

for  hydro-salpinx,  476,  499 

—  for  hydrostatic  dilatation  of  blad- 
der,  94 

for  hypertrophic     elongation     of 

cervix,   177 

for     hypertrophied      clitoris     or 

vulva,   103,   109 

for  imperforate  hymen,  94 

— —  for  inflammation   of   uterine   ap- 
pendages, 319 

for  inflammation  of  uterus,   212 

for  injury  to  uterus,  319 

for  inverted  uterus,  450 

— ■ —  for  lacerated  cervix,   169,   177 

for  leucoplakic  vulvitis,  103 

for      leucorrhcea      with       severe 

erosion,   177 
for  malignant  disease  of  vagina, 

138 

for  mucous  polypus,   195 

for  myomata  of  uterus,  413 

for  myomatous  polypus,  197,  199 

for  new  growths  in  uterus,   212, 

319 

for  ovarian  abscess,  217 

for  ovarian    cysts    and    tumours, 

217 
for  ovarian  prolapse,  494 

for  ovarian  tumours,  452 

for  pain  due  to  coccyx,   125 

for  pelvic  deformity,  421 

for  placental  polypus,  202 

for    posterior     cervical     myoma, 

357 

for  prolapse   of   anterior   vaginal 

wall,   139 


716 


INDEX 


Operation    for    prolapse    of    posterior 
vaginal  wall,   142 

for  prolapse  of  urethra,  90 

for  pseudo-broad-ligament    cyst, 

47i 

for  pyo-salpinx,   476 

for  rectocele,   109 

for  relaxed  vaginal  outlet,   109 

for  retained  products  of  concep- 

tion,  191 

for  retroverted  uterus,  438,  443 

for  rupture  of  uterus,   212 

for  ruptured  perineum,   109 

for  salpingitis,  217,  476 

for  scar-hernia,  639 

for  septic  uterus,  319 

for    submucous    myomata,    203, 

206 
for  suburethral  abscess,  92 

for  transverse  septum  of  vagina, 

127 

for  tubal  carcinoma,  476 

for  tubal  gestation,  216,  476 

for     tubo-ovarian    abscess,     476, 

494 

for  tubo-ovarian  cysts,   476,  494 

for  urethral  caruncle,  87 

for  urethrocele,   93 

for  urethro-vaginal  fistula,   144 

for  utero-vesical  fistula,   184 

for  vaginal  cysts,   137 

for  vaginal  myoma,   135 

for  vaginal  septum,  129,  130 

for  vaginismus,   131 

for  varicose  veins  of  vulva,  102 

for  vesico-vaginal  fistula,  145 

for  warts  of  vulva,  103 

tables,  52 

—  wounds  of  bladder,   539,   540 

of  bowel,   545 

of  ureter,  540 

Operations,     results    of     (see    Results, 

immediate,  and  After -results) 

in  private  houses,   65 

major  (see  Major  operations) 

minor  (see  Minor  operations) 

Operative  manipulation,   5 
Ovarian  cysts,  irremovable,  461 

suspension,  494 

tumours  and  labour,  513 

and  pregnancy,   512 

and  puerpery,   515 

Ovaries,  conservation  of,  225 
removal  of,  in  vaginal  hysterec- 
tomy, 252 
Ovariotomy,    after  -  results    of,    701, 

703 
and  hysterectomy,  462 

—  causes  of  death  after,  686 
difficulties  of,  460 

immediate  results  of,  686 

indications  for,  452 

premature  labour  after,  513 

technique  of,  452 

Ovary,  partial  resection  of,  497 
Overalls,  62 


Packing,  intra-uterine,  45 

vaginal,  45 

Pain  after  operation,   590 

as  after -result  of  operation,  696 

Painful   micturition   as   after-result   of 

operation,  697 
Paquelin's  cautery,  21 
Paravaginal  section,  245,  263 
compared  with  Wertheim's 

operation,   369 
Parotitis,  postoperative,  619 
Patient,  communications  to,   76 
Pedicles,  tying,  38 
Pedunculated     subperitoneal     myoma, 

4i5 
Perchloride  of  mercury,  32 
Perforation  of  uterus  in  curetting,  191 
of  uterus  in  enucleation  of  myo- 
mata, 205 
Perineoplasty,   dangers  of,   122 

dressing  after,   565 

for  complete  rupture,   117 

for  incomplete  rupture,   109 

immediate  results  of,  692 

Peritoneal  saline  solution,  580 
Peritonitis  after  cervical  dilatation,  167 

postoperative,   598 

general,  600 

local,   603 

Periurethral  abscess,  immediate  results 

of  operations  for,   693 
Peroxide  of  hydrogen,   33 
Phthisis,  postoperative,  651 
Placental  polypus,  202 
Pleating  suture,  37 
Pleurisy,  postoperative,  651 
Pneumonia,  postoperative  lobar,  651 

postoperative  septic,   651 

Polypus  of  body,   mucous,    195 

of  body,  myomatous,   199 

of  cervix,  mucous,   195 

of  cervix,  myomatous,   197 

placental,  202 

Position  of  patient  after  operation,  568 
Posterior  colporrhaphy,   142 
Postoperative  abdominal  sinus,  632 

abscess  of  abdominal  wound,  629 

acute  nephritis,   660 

phthisis,   651 

bedsores,   670 

bronchitis,   650 

broncho-pneumonia,   650 

burns,  673 

bursting  of  abdominal  wound,  636 

cellulitis,   605 

cerebral  hemorrhage,   667 

thrombosis,   667 

conjunctivitis,  672 

constipation,  626 

crushes  and  dislocations,   672 

cutaneous  eruptions,  667 

cystitis,  655 

diabetic  coma,  663 

diarrhoea,  627 

dilatation  of  stomach,  622 

dislocations  and  crushes,  672 


INDEX 


717 


Postoperative  distension,  586 

drug-poisoning,  668 

embolism  of  femoral  artery,  622 

emphysema    of    abdominal    wall, 

644 
fat-embolism,  653 

fistula  of  large  intestine,  634 

of  small  intestine,  635 

gangrene  of  bowel,  625 

of  lung,  651 

haematoma  of  abdominal  wound, 

629 

haemorrhage  and  shock,  592 

from  bowel,  625 

—  from  stomach,   624 

heart-failure,  616 

hiccough,  623 

hydro-nephrosis,  662 

hyperpyrexia,  617 

incontinence  of  urine,   658 

insanity,  665 

insomnia,  591 

jaundice,  667 

mesenteric  embolism,  665 

thrombosis,   665 

miscarriage,  670 

obstruction,  606 

pain,  590 

painful  micturition,   655 

parotitis,  619 

peritonitis,  598 

pleurisy,  651 

pneumonia,   651 

posture  paralysis,   671 

prolapse  of  Fallopian  tube,  649 

pulmonary  embolism,  651 

pyaemia  and  septicaemia,  617 

pyelitis,  660 

pyelo-nephritis,   660 

pylephlebitis,  619 

pyo-nephrosis,   662 

retention  of  urine,   654 

scar-hernia,  637 

septicaemia  and  pyaemia,   617 

shock  and  haemorrhage,  592 

sloughing   of   abdominal   wound, 

631 

suppression  of  urine,  656 

temperature,  550 

tetanus,  618 

— —  thirst,  552 

thrombosis  of  femoral  vein,  620 

of  inferior  vena  cava,  622 

treatment,  347 

vaginal  discharge,   647 

vesico-abdominal     and     uretero- 

abdominal  fistulas,  659 

vomiting,   582 

Posture  paralysis,   671 
Pregnancy  and  operation,  75 
Premature  labour  after  ovariotomy,  513 
Preoperative  examination,  71 
Preparation  of  patient  at  operation,  85 

of  patient  for  major  operations,  82 

of  patient  for  minor  operations,  78 

of  room  for  private  operations,  66 


Preparation  of  staff  at  operation,  84 
Preservation   of   specimens,    150 
Private  operations,  nurse's  duties  at,  65 

outfit  for,  65 

sterilized  outfit  for,  30 

Products  of  conception,  removal  of,  191 
Prolapse,  immediate  results  of  opera- 
tions for,  693 

of  urethra,  90 

Pseudo-broad-ligament  cysts,  471 
Pulmonary    complications,    postopera- 
tive, 650 

disease  and  operation,   73 

—  embolism,  postoperative,   651 
Pulse  after  operations,   549 
Purse-string  suture,  37 
Pyaemia,  postoperative,   617 
Pyelitis,  postoperative,  660 
Pyelo-nephritis,  postoperative,  660 
Pylephlebitis,  postoperative,  619 
Pyocolpos,  immediate  results  of  opera- 
tions for,  693 
Pyometra,  immediate  results  of  opera- 
tions for,  693 
Pyo-nephrosis,  postoperative,  662 
Pyo-salpinx,  rupture  of,  in  dilatation  of 
cervix,   166 


Radical  abdominal  operation  (see  Wert- 

heim's  operation) 
—  hystero-vaginectomy  (see  Hystero- 

vaginectomy) 
Rectal  injections,  injuries  from,  627 

saline  injection,  580 

tube,     use    of,     after    operations, 

556 

wash-out  for  distension,  588 

Recto-vaginal  fistula,  immediate  results 

of  operations  for,  693 
Reef  knot,  38 

Remote  results  (see  After-results) 
Removal   of   appendage   on   one   side, 
after-results  of,  701 

of  both  appendages,  after-results 

of,  703 
of     pseudo -broad-ligament    cyst, 

47i 
Renal  disease  and  operation,   74 
Resection  of  ovary,  partial,   497 
Respiration  after  operation,   550 
Respiratory  failure  under   anaesthetic 

675 
Results,  immediate,  of  abdominal  myo 
mectomy,  685 

of  abdominal  subtotal  hys- 

terectomy, 681 
of  abdominal  total  hysterec- 
tomy, 679,  680 

of  amputation  of  cervix,  693 

of  Caesarean  section,  691 

of  colpo-perineoplasty,  692 

of  colporrhaphy,  692 

of  dilatation  of  cervix,  692 

of  dilatation  of  cervix  and 

curetting,  692 


7i8 


INDEX 


Results,  immediate,  of  excision  of 
Bartholinian  abscess,  693 

of  excision  of  Bartholinian 

cyst,   693 

of  excision  of  urethral  mu- 
cous membrane,  693 

■ of.  excision  of  vaginal  cyst, 

693 

of      excision      of      vaginal 

tumour,  693 

■ of  excision   of   vulva,    693 

■ of  gynaecological  operations 

in  general,  677 

of  intraperitoneal    shorten- 
ing  of   round   ligaments, 
689 
—  of  major  operations,  679-92 

of    minor    operations,    692, 

693 

of  operations  for  dyspareu- 

nia,  692 

of  operations  for  extra- 
uterine gestation,   690 

of  operations   for  hsemato- 

colpos,   693 

of  operations   for  haemato- 

metra,  693 

of    operations    for    mucous 

polypus,  692 

of  operations  for  myoma- 
tous polypus,  692 

of    operations    for    periure- 
thral abscess,  693 
—  of  operations  for  prolapse, 
693 

of  operations  for  pyocolpos, 

693 

of  operations  for  pyometra, 

693 

of  operations  for  recto- 
vaginal fistula,  693 

of    operations    for    urethral 

caruncle,  693 

of  operations  for  vaginis- 
mus, 692 

of  operations  for  vesico- 
uterine fistula,  693 

of  operations  for  vesico- 
vaginal fistula,  693 

of  ovariotomy,  686 

of  perineoplasty,  692 

of  radical  operation  for  cer- 
vical carcinoma,  683,  684 

of      salpingo-oophorectomy 

and  salpingectomy,    687, 
688 

of  trachelorrhaphy,  692 

of     vaginal     hysterectomy, 

682,  683 

of     vaginal     myomectomy, 

692 

of  ventro-suspension,  689 

of  all  major  operations,   694 

remote  (see  After-results) 

Retention  of  urine,  postoperative,  654 

Retractor,  clip,  14 


Retractors,   12 

vaginal,  14 

Retroperitoneal  haimatoma,  43 
Retroversion  of  uterus  after  removal 

of  diseased  appendages,  697 
Ries,  of  Chicago,   361 
Ring  forceps,   10 
Round-ligament  forceps,   11 
Round       ligaments,       intraperitoneal, 

shortening  of,  443 


Saline  solution,  composition  of,  573 

methods    of    administering, 

573 
Salpingectomy,  subtotal,  497 

total,  498 

Salpingitis  after  cervical  dilatation,  166 
Salpingo  -  oophorectomy,       alternative 
technique  for,   493 

bisection  of  uterus  in,  485 

causes  of  death  after,  688 

dangers  of,  489 

difficulties  of,  485- 

immediate  results  of,  687 

indications  for,  476 

technique  of,  477 

■  with  hysterectomy,  316 

Salpingostomy,  499 
Sanitas,  33 
Scalpel,  8 

carrier,  Berkeley's,   8 

Scalpels,  sterilization  of,   8,  33 
Scar-hernia,  637,   696 

operation  for,   639 

Schauta's  paravaginal  section,   369 

Scissors,   1 1 

Septicaemia,  postoperative,  617 

Septum,  longitudinal,  of  vagina,  130 

Sharp  spoon,   20 

Shock,  postoperative,   592 

remote,   597 

Shot-and-coil  forceps,   n 

ligature,   11 

Silk-box,   18 
Silk  ligatures,   23 

sterilization  of,  30 

Silkworm-gut  ligatures,   23 
Simple  continuous  suture,  36 

interrupted  suture,  35 

Sinus,  abdominal,  632 
Skin,  sterilization  of,  33,  34 
Sloughing  of  abdominal  wound,  631 
Sound,   19 

Specimens,  fixation  and  preservation  of, 

49 
Speculum,  Auvard's,   13 
Speed  in  operating,  4 
Spencer's  operating  table,  21 
Spencer  Wells'  forceps,  9 
Spirit  solution,   Lockwood's,   32 
Staff  of  operating  theatre,   57 

of    operating   theatre,    duties  "of, 

58 
Steam  sterilization,  28 
Sterilization  by  boiling,  31 


INDEX 


719 


Sterilization  by  chemicals,  31 

by  dry  heat,  27 

by  steam,  28 

methods  of,  27 

of  gloves,  30 

of  hands,  34 

of  scalpels,  8 

of  silk,   30 

of  skin,  33,   34 

of  swabs,   25 

Sterilized  outfit  for  private  operations, 
30 

Sterilizer-drum  for  emergency  opera- 
tions, 31 

Sterilizing-room,  56 

Stomach,  postoperative  acute  dilata- 
tion of,  622 

haemorrhage  from,  624 

Strapping  of  abdominal  wound,  632 

Strychnine,  use  of,  before  serious  opera- 
tions, 670 

Subcutaneous  saline  injection,   578 

Submucous  myomata,   203,  206 

Subtotal  and  total  hysterectomy  com- 
pared, 218 

hysterectomy    by  routine    clamp 

method  (see  Hysterec- 
tomy) 

by  routine  ligature  method 

(see  Hysterectomy) 

Suburethral  abscess,  91 

Suppression  of  urine,  postoperative 
656 

Surgeon,  bearing  of,   1 

Surgeon's  dressing-room,  55 

knot,  38 

Surgery,  aseptic,  31 

Surgical  technique,  7 

Suspension  of  ovary,  494 

Suture  of  abdominal  wound,  513,  518 

material,  23 

Sutures,  varieties  of,  35-37 

Swab  nurse,  duties  of,  60 

Swabs,  counting  of,  27 

for  abdominal  operations,  25 

for  vaginal  operations,  25 

— : —  material  for,  25 

method  of  making,  25 

number  required,  26 

sterilization  of,  25 

Symptoms,  menopausal,  after  opera- 
tion, 699 

persistence  of,  after  operation,  699 

return  of,  after  operation,  699 

Tables,  operating,  21,   52 

Technique,  surgical,  7 

Temperature,  postoperative,  550 

Tetanus,  postoperative,   618 

Thirst,  postoperative,   552 

Thread  ligatures,  23 

Thrombosis    of     femoral     vein,    post- 
operative,  620 
—  of  inferior  vena  cava,  postopera- 
tive, 622 


Thrombosis    of     mesenteric      arteries, 

postoperative,  665 
Thyroid  tumours  and  operation,  75 
Tissues,  fixation  of,  49 
Toilet  of  patient  after  operation,   568 
Tongue  after  operation,   551 
Total  and  subtotal  hysterectomy  com- 
pared, 218 

hysterectomy  (see  Hysterectomy, 

abdominal,  total) 
Tracheoplasty,   173 
Trachelorrhaphy,   169 

immediate  results  of,  692 

Tubal  gestation  (see  Extra-uterine  ges- 
tation) 

Tubo-ovarian  abscess,  494 
—  cyst,  494 


Ureter,     cut,     implantation     of,     into 
bladder,  540 

injuries  to,   251,   395,   468,    540, 

658,  659 

Uretero-ureteral  anastomosis,  544 
Uretero-vesical  anastomosis,   540 
Urethral  caruncle,  immediate  results  of 
operations  for,  693 

operations  for,  87 

prolapse,  operation  for,   90 

Urethrocele,  operation  for,  93 
Urethro-vaginal  fistula,   144 
Uterine  artery,  rupture  of,  in  dilatation 
of  cervix,   161 

displacement,       after-results      of 

operations  for,  707 

myomata  and  labour,  518 

and  pregnancy,  516 

and  puerpery,  519 

Utero-vesical  fistula,   184 

Uterus,  perforation  of,  in  dilatation  of 

cervix,   162 
Utriculoplasty,  434 


Vagina,  absence  of,  128 

atresia  of,   127 

cysts  of,   137 

dressings  for  operations  on,  45 

longitudinal  septum  of,  130 

myoma  of,   135 

packing  of,  45 

removal  of,   138 

transverse  septum  of,   127 

Vaginal   and  abdominal  hysterectomy 

compared,   222 
clamp,   14 

discharge,  33,   647 

douching,  34 

hysterectomy  (see  Hysterectomy, 

vaginal) 

irrigation,  33 

myomectomy,  immediate  results 

of,  692 
—  operations,  dressing  after,  567 

preparation   of  patient  for, 

78 


720 


INDEX 


Vaginal  operations,  swabs  for,   25 

retractors,   14 

section,  dressing  for,  45 

Vaginectomy,  partial,   138 
Vaginismus    and    dyspareunia,    imme- 
diate results  of  operations  for, 
692 

plastic  operation  for,  132 

stretching  orifice  for,  131 

Varicose  veins  of  vulva,  101 

Vena      cava,      inferior,     postoperative 

thrombosis  of,  620 
Ventro-fixation,  443 
Ventro -suspension  of  uterus,  438 

of  uterus, causes  of  death  after, 690 

of  uterus,  dangers  of,   441 

of  uterus,  immediate  results  of, 689 

Vesico-uterine  fistula,  immediate  results 

of  operations  for,   693 
Vesico-vaginal  fistula,   145 
immediate  results  of  opera- 
tions for,   693 
Visitors  after  operation,  570 

at  operations,   56 

Volsella  forceps,   n 
Vomiting,   anaesthetic,   582 

irritative,  583 

neurotic,  584 


Vomiting,  obstructive,   585 

peritonitic,  585 

Vulva,  dressings  for  operations  on,  45 

excision  of,   103 

operation  for  hasmatoma  of,  102 

varicose  veins  of,   101 

warts  of,   103 

Vulval  operations,   dressing  after,   566 


Warts  of  vulva,   103 

Wash-out,  rectal,  for  distension,  588 

Wertheim's  operation,   361 

■ compared  with  paravaginal 

section,  369 

complications  of,  399 

difficulties  and  dangers  of, 

393 

limits  of,  376 

mortality  of,  363 

operability  rate  of,  365 

percentage     of      cures      in, 

366 

technique  of,  378 

vaginal  clamp  for,    14 

Worrall's  needle,   17 
Wounds,  application  of  antiseptics  to, 
33 


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1911 


Berkeley 
A  text-book  of  gynaecological 


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19  j  I 


